Respiratory Flashcards
1
Q
Where should the needle be inserted in thoracocentesis in tension pneumothorax?
A
2nd intercostal space, mid-clavicular line
2
Q
What is the discrepency in NICE and BTS/SIGN guidance for stepwise asthma management?
A
- NICE: SABA –> low dose ICS –> LTRA trial –> + LABA (fixed dose or MART) –> medium dose ICS –> specialist
- BTS/SIGN: SABA –> low dose ICS –> + LABA (fixed dose or MART) –> medium dose ICS OR LTRA –> specialist
3
Q
Which type of malignancy is a patient with asbestosis most likely to develop?
A
lung cancer (NOT mesothelioma)
4
Q
What are typical findings of asbestosis on lung function tests?
A
severe restrictive ventilatory defect; reduced gas transfer
5
Q
What 5 things may be recommended in acute bronchitis (not pneumonia)?
A
- honey
- pelargonium (herbal medicine)
- cough medicine containing guaifenesin (expectorant)
- cough suppressant (except codeine)
- if abx - doxycycline
6
Q
What abx do NICE recommend for pneumonia?
A
- CRB65 0 - amoxicillin
- CRB65 1-2 - amox + clari/erythromycin
7
Q
How is a diagnosis of TB confirmed?
A
sputum culture - 3 spontaneous deep cough samples, 1 preferably early morning. send for AFB, mycobacterium culture, genetic testing
8
Q
What is a ghon focus + ghon complex?
A
(seen in TB)
ghon focus = initial caseating granulomatous lesion in upper lung lobe
ghon complex = calcified ghon focus + associated mediastinal lymphadenopathy
9
Q
What is the treatment of active TB?
A
- RIPE: rifampicin, isoniazid, pyrazinamide, ethambutol 2 months
- continued treatment: RI 4 months
10
Q
What is the treatment of latent TB?
A
- rifampicin + isoniazid for 3 months OR
- isoniazid for 6 months
+ give pyridoxine
11
Q
What may be seen on CXR in asbestosis?
A
bilateral lower zone interstitial changes, pleural plaques/thickening (may be normal)
12
Q
Which occupations are at risk of berylliosis?
A
aerospace, nuclear, telecommunications, semiconductor or electrical industries
13
Q
What are 3 types of lung disease that beryllium exposure can cause?
A
- beryllium sensitisation - allergic disease
- acute beryllium disease - acute pneumonitis
- chronic beryllium disease - chronic granulomatous disease similar to sarcoidosis
14
Q
Which occupation is affected by silicosis?
A
coal miner (& foundries + sandblasting)
15
Q
What are 2 types of lung disease coal miners can get?
A
silicosis, coal workers’ pneumoconiosis
16
Q
What are 2 types of coal workers’ pneumoconiosis?
A
- simple coal workers’ pneumoconiosis (asymptomatic)
- progressive massive fibrosis (if associated with RA = Caplan’s syndrome)
17
Q
What is the management of whooping cough (Bordetella pertussis)?
A
Azithromycin or clarithromycin if onset within last 21 days; admit infants <6 months. Notifiable disease. Prophylaxis to household contacts
18
Q
What are the 3 phases of whooping cough?
A
- Catarrhal phase - similar to viral URTI, 1-2 weeks
- Paroxysmal phase - cough worsens, inspiratory whoop 2-8 weeks
- Convalescent phase - cough subsides over weeks to months
19
Q
What are the school exclusion rules for whooping cough?
A
48h after started antibiotics or 21 days after onset of symptoms
20
Q
What is the vaccination guidance for whooping cough in pregnancy?
A
All pregnant women 16-32 weeks should be offered vaccine
21
Q
What is the inheritance pattern of alpha-1 anti-trypsin deficiency?
A
autosomal recessive / co-dominant
22
Q
What will an obstructive picture on spirometry (e.g. COPD) show?
A
reduced FEV1, reduced FEV1/FVC <0.7, normal FVC
23
Q
How can the liver be affected in A1AT deficiency?
A
cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
24
Q
What are the different types of alleles and genotypes for A1AT deficiency?
A
alleles classified by electrophoretic mobility - M = normal, S= slow, Z = very slow
PiMM = normal
PiMZ = heterozygous
PiSS = 50% normal A1AT levels
PiZZ = 10% normal A1AT levels
25
What is the pathophysiology of A1AT deficiency?
A1AT is a protease inhibitor normally produced by the liver; protects cells (including alveoli) from enzymes such as neutrophil elastase. When deficient leads to panacinar emphysema most marked in lower lobes
26
What will chest CT often show in silicosis?
bilateral upper lobe lung nodules and eggshall calcification of lymph nodes
27
What are 2 cardiac effects of carbon monoxide poisoning?
1. tachyarrhythmias
2. myocardial ischaemia
28
What are 5 neurologic changes seen in carbon monoxide poisoning?
1. hemi- and monoplegia
2. cerebellar signs
3. parkinsonism
4. akinetic mutism
5. coma
29
What deramtological changes may be seen in carbon monoxide poisoning?
cherry-red colour of the skin and mucosa (not cyanosis)
30
What are 6 risk factors for COPD?
1. tobacco smoking
2. occupational exposure - dusts, fumes, chemicals
3. air pollution
4. genetics - A1ATD
5. Lung development - maternal smoking, severe RTI in childhood
6. **Asthma**
31
How is COPD severity categorised?
* Stage 1 - Mild: **FEV1** >80%
* Stage 2 - Moderate: 50-80%
* Stage 3 - Severe: 30-50%
* Stage 4 - Very severe - <30%
32
What ENT manifestation can occur with Mycoplasma pneumonia?
bullous myringitis
33
Which atypical pneumonia may be associated with diarrhoea?
Legionella
34
What is the commonest cause of acute bronchitis?
virus (rhinovirus, enterovirus, influenza, parainfluenza, coronavirus)
35
What is the recommended antibiotic treatment for low severity CAP?
Amoxicillin first-line - 5 days
36
What is the management for moderate to high severity CAP?
Amoxicillin + macrolide 7-10 day course (consider co-amoxiclav / ceftriaxone / tazocin if severe)
37
What are the discharge criteria post admission with CAP?
Delay discharge if have 2 or more in last 24h of:
* fever > 37.5
* resp rate > 24
* HR > 100
* SBP < 90
* sats < 100% RA
* confusion
* unable to eat without assistance
38
What are 3 factors which may improve survival in COPD?
1. Smoking cessation (number 1)
2. LTOT
3. Lung volume reduction surgery
39
What is the benefits of ICS therapy in COPD?
Reduces frequency of exacerbations
40
What are the 2 criteria for considering a PDE-4 inhibitor E.g. roflumilast for COPD?
- Severe COPD - FEV1 after bronchodilator < 50%
- 2 or more exacerbations in past 12 months despite triple therapy with LAMA, LABA and ICS
41
What are 7 criteria for a patient with COPD to be started on azithromycin prophylaxis?
- don’t smoke
- continued exacerbations
- on optimum standard therapy
- CT thorax to exclude brinchiectasis
- sputum culture to exclude atypical infection and TB
- ECG for QTc
- LFTs
42
What are 6 CXR findings in mesothelioma?
1. obliteration of diaphragm
2. nodular thickening of pleura
3. decreased size of involved chest
4. radiolucent sheetlike encasement of pleura
5. loculated effusion >50% of patients
43
How is a diagnosis of mesothelioma made?
pleural biopsy
44
What is the management of mesothelioma?
symptomatic only - palliative surgery (extrapleural pneumonectomy, plerectomy + decortication)
45
What features may be seen on HRCT in IPF?
* bilateral interstitial shadowing - small, irregular, peripheral opacities 'ground glass'
* progresses to honeycombing
46
What are 2 blood tests which may be positive in IPF?
* ANA +ve 30%
* RF +ve 10%
47
What are 4 aspects of the management of pulmonary fibrosis?
1. pulmonary rehabilitation
2. antifibrotics - pirfenidone, nintendanib
3. supplementary O2
4. lung transplantation
48
What are the 3 criteria for a patient with COPD to have a rescue pack (short course oral steroids + oral abx) at home as part of exacerbation action plan?
1. 1 exacerbation in last year + remain at risk of exacerbations
2. understand + confident re when + how to take, + associated benefits / harms
3. know to tell healthcare professional when they have used the medicines, + ask for replacements
49
What are 4 organisms commonly implicated in bronchiectasis?
1. Haemophilus influenzae (most common)
2. Klebsiella
3. Pseudomonas aeruginosa
4. Streptococcus pneumoniae
50
What is the commonest cause of bronchiectasis today in children + young adults?
cystic fibrosis
51
What proportion of patients with bronchiectasis have digital clubbing?
50%
52
What may be seen on CXR in bronchiectasis?
'tram tracking' appearance of dilated lower lobe bronchi
53
What are 7 things that management of bronchiectasis involves?
1. prolonged use of antibiotics
2. postural drainage + chest physio
3. inhaled steroid
4. surgery to treat localised bronchiectasis
5. antibiotics - exacerbations + long term
6. bronchodilators - selected cases
7. immunisations
54
What is the equation used to calculate anion gap?
[sodium + potassium] - [bicarbonate + chloride]
55
When is an anion gap useful in interpreting ABGs?
metabolic acidosis - normal vs raised have different causes
56
What are 5 causes of a metabolic acidosis with normal anion gap?
1. GI bicarb loss: diarrhoea, ureterosigmoidostomy, fistula
2. renal tubular acidosis
3. drugs e.g. acetazolamide
4. ammonium chloride injection
5. Addison's disease
57
What are 5 causes of a metabolic acidosis with normal anion gap?
1. lactate: shock, hypoxia
2. ketones: diabetic ketoacidosis, alcohol
3. urate: renal failure
4. acid poisoning: salicylates, methanol
5. 5-oxoproline: chronic paracetamol use
58
What is the range for a normal anion gap?
8-14 mmol/L
59
What is the management of primary pneumothorax?
* if rim of air <2cm and no SOB - consider discharge
* if >2cm OR SOB - needle decompression (aspiration) - if fails chest drain
60
What is the management of secondary pneumothorax?
* if <1cm - give O2 and admit for 24h
* if rim of air 1-2cm, no SOB - aspiration
* if >2cm or SOB - chest drain
61
What is the first line management of iatrogenic pneumothorax?
majority resolve with observation - if treatment required, aspiration used
62
What is the management of persistent / recurrent pneumothorax?
VATS (video-assisted thoracoscopic surgery) - for mechanical / chemical pleurodesis +- bullectomy
63
What is the guidance for aeroplane travel in PTX?
* patients may travel 2 weeks after successful drainage if no residual air
* BTS now recommend can fly 1 week post CXR (previously 6 weeks)
64
What is the guidance for scuba driving in PTX?
driving should be permanently avoided unless patient has had bilateral surgical plerectomy + normal lung function and chest CT
65
What are 3 indications per the BTS for placing a chest drain in a pleural effusion?
1. frankly **purulent** or **turbid/cloudy** fluid on tap
2. presence of **organisms** identified by Gram stain and/or culture
3. pleural fluid **pH < 7.2** with suspected pleural infection
66
How should pleural aspiration be performed for a pleural effusion?
US guided, use 21G need and 50ml syringe
67
What are 5 things that pleural fluid should be sent for following aspiration of pleural effusion?
1. pH
2. protein
3. lactate dehydrogenase (LDH)
4. cytology
5. microbiology
68
What are Light's criteria for exudate/transudate?
* Protein: < 25g/L is transudate, > 35g/L is exudate
* if 25-35g/L, exudate is:
1. pleural fluid protein / serum protein >0.5
2. pleural fluid LDH / serum LDH >0.6
3. pleural fluid LDH more than 2/3 upper limits of normal serum LDH
69
What are 2 things that a low pleural fluid glucose could suggest is the underlying cause?
1. rheumatoi arthritis
2. tuberculosis
70
What are 2 things that a raised pleural fluid amylase could suggest is the underlying cause?
1. pancreatitis
2. oesopahgeal perforation
71
What are 3 things that heavily blood-stained pleural fluid could suggest is the underlying cause?
1. mesothelioma
2. pulmonary embolism
3. tuberculosis
72
What are 4 options for managing recurrent pleural effusion?
1. recurrent aspiration
2. pleurodesis
3. indwelling pleural catheter
4. drug maangement to allevaite symptoms e.g. opioids to relieve dyspnoea
73
For how long should nicotine replacement therapy, buproprion or varenicline be prescribed?
until **2 weeks** after **target stop date**
* NRT - usually after 2 weeks
* buproprion + varnicline - after 3-4 weeks
74
When should a further prescription of NRT/varenicline/bupropion be provided beyond 2 weeks after the patient's target stop smoking date?
only in patients who have demonstrated their quit attempt is continuing
75
Can combinations of NRT/varenicline/bupropion be used?
no - shouldn't be offered in any combination
76
What are 3 adverse effects of NRT?
1. nausea + vomiting
2. headaches
3. flu-like symptoms
77
What type of prescription of NRT do NICE recommend in people with high level of dependence / single form inadequate?
combination of patches + another form (e.g. gum, inhalator, lozenge or nasal spray)
78
What is the mechanism of action of varenicline?
nicotinic receptor partial agonist
79
When should varenicline be started in relation to the target smoking stop date?
1 week before
80
What is the recommended course of treatment of varenicline?
12 weeks
81
What are 5 adverse effects of varenicline?
1. use with cation in h/o depression / self-harm ?increase in suicidal behaviour
2. nausea (commonest)
3. headache
4. insomnia
5. abnormal dreams
82
Which smoking cessation therapy should be used in caution in patients with a history of depression?
varenicline
83
When is varenicline contraindicated?
pregnancy and breastfeeding
84
What is the mechanism of action of bupropion?
noradrenaline and dopamine reuptake inhibitor, and nicotinic antagonist
85
When should bupropion be prescribed for smoking cessation, in relation to target quit date?
1-2 weeks before patient's target stop date
86
What are 4 contraindications of bupropion?
1. epilepsy (risk of seizures)
2. pregnancy
3. breast feeding
4. eating disorder - relative CI
87
Which smoking cessation therapy is contraindicated in epilepsy?
bupropion
88
Which smoking cessation therapy should be used in caution in those with an eating disorder?
bupropion - relative contraindication
89
What is done to assess for smoking in pregnant women?
all women should be tested for smoking using carbon monoxide detectors
90
Which pregnant women should be referred to NHS stop smoking services?
all women who smoke, stopped in the last 2 weeks, or with CO Reading 7 ppm or above
91
What are the first-line stop smoking interventions in pregnancy?
CBT, motivational interviewing, structured self-help and support from NHS Stop Smoking Services
92
What is the guidance regarding NRT in pregnancy?
* should be used if CBT/MI/structured self help/support don't work - should remove patches before going to bed
* evidence is mixed
* doesn't affect baby's birthweight
93
Can varenicline / bupropion be used in pregnancy?
no - both CI
94
What are 2 types of metabolic acidosis secondary to high lactate levels?
1. type A: sepsis, shock, hypoxia, burns
2. type B: metformin
95
Which 3 abx are options to treat exacerbations of chronic bronchitis?
amoxicillin or tetracycline or clarithromycin
96
What abx is first line to treat uncomplicated CAP?
amoxicillin (doxy or clari if allergic, add fluclox if staph suspected e.g. in influenza)
97
What abx is first line in pneumonia caused by atypical pathogens?
clarithromycin
98
What abx is first line first HAP acquired within 5 days of admission?
co-amoxiclav or cefuroxime
99
Which abx is first line for HAP acquired >5 days after admission?
tazocin OR broad spec cephalosporin (e.g. ceftazidime) OR quinolone e.g. cipro
100
What pathology is seen in sarcoidosis on imaging?
non-caseating granulomas
101
What are 2 skin changes seen in sarcoidosis?
* lupus pernio
* erythema nodosum
102
Why is hypercalcaemia seen in sarcoidosis?
macrophages inside granulomas cause increased conversion of vitamin D to its active form (1, 25-dihydroxycholecalciferol)
103
What are 3 syndromes associated with sarcoidosis?
1. **Lofgren's syndrome** - bilateral hilar lymphadeompathy, erythema nodosum, fever, polyarthralgia - severe form
2. **Mikulicz syndrome** - enlarged parotid + lacrimal glands due to sarcoidosis, TB or lymphoma
3. **Heerfordt's syndrome** (uveoparotid fever) - parotid enlargement, fever + uveitis
104
What follow up is required for pleural plaques?
they are not malignant (benign), not associated with increased riks of lung cancer/mesothelioma - no followup necessary
105
What is the mechanism of action of rifampicin?
inhibits bacterial DNA dependnet RNA polymerase preventing transcription of DNA into mRNA
106
What are 4 adverse effects of rifampicin?
1. potent liver enzyme inducer
2. hepatitis
3. orange secretions
4. flu-like symptoms
107
What is the mechanism of action of isoniazid?
inhibits mycolic acid synthesis
108
What are 4 adverse effects of isoniazid?
1. **peripheral neuropathy - B6 deficiency (pyridoxine)**
2. hepatitis
3. agranulocytosis
4. liver enzyme inhibitor
109
What is the mechanism of action of pyrazinamide?
converted by pyrazinamidase into pyrazinoic acid - inhibits fatty acid synthase (FAS) I
110
What are 4 adverse effects of pyrazinamide?
1. hyperuricaemia causing gout
2. arthralgia
3. myalgia
4. hepatitis
111
What is the mechanism of action of ethambutol?
inhibits enzyme arabinosyl transferase which polymerises arabinose into arabinan
112
What is are 2 side effects of ethambutol?
1. **optic neuritis** - check visual acuity before + during treatment
2. adjust dose in renal impairment
113
What is a general side effect of starting anti-tuberculous therapy?
immune reconstitution disease - occurs 3-6 weeks after starting treatment, presents with enlarging lymph nodes
114
What are 3 groups who are treated for TB with directly observed therapy (3x a week dosing regimen)?
1. homeless with active TB
2. patients likely to have poor adherence
3. prisoners with active or latent TB
115
What are normal carboxyhaemoglobin levels depending on patient group?
* <3% non-smokers
* <10% smokers
* 10-30% symptomatic CO poisoning: headache, vomiting
* >30%: severe CO toxicity
116
For how long should oxygen therapy be continued in CO poisoning?
until symptoms have resolved (rather than until CO improves on gases)
117
What most commonly causes lung abscess?
aspiration pneumonia
118
Is it more typical for lung abscesses to by polymicrobial or monomicrobial?
polymicrobial
| monomicrobial causes: staph aureus, klebsiella, pseudomonas
119
What intervention may be required for a lung abscess that is not resolving?
percutaneous drainage
120
# W
What is the commonest genetic abnormality in cystic fibrosis?
delta F508 on long arm chromosome 7
121
What are 4 organisms which colonise cystic fibrosis patients?
1. Staphylococcus aureus
2. Pseudomonas aeruginosa
3. Burkholderia cepacia
4. Aspergillus
122
What will spirometry show in idiopathic pulmonary fibrosis?
* normal or increased FEV1/FVC ratio
* reduced FVC
* TLCO reduced (impaired gas exchange)
123
What are 2 blood tests that may be positive in idiopathic pulmonary fibrosis?
* ANA positive 30%
* Rheumatoid factor positive 10%
124
What are 3 aspects of management in idiopathic pulmonary fibrosis?
1. pulmonary rehabilitation
2. pirfenidone (antifibrotic) in some patients
3. supplementary O2 and eventually lung transplant
125
What is the average life expectancy in IPF?
3-4 years
126
What are 2 indications for 2ww referral for lung cancer?
1. CXR findings suggesting lung cancer
2. > 40 years with unexplained haemoptysis
127
What are 6 indications for an urgent CXR (wihtin 2 weeks) to assess for lung cancer in patients over 40?
2 or more of the following or ever smoked and 1 or more:
* cough
* fatigue
* SOB
* chest pain
* weight loss
* appetite loss
128
Waht are 5 indications to *consider* urgent CXR (within 2w) for people aged >40 years?
1. persistent or recurrent chest infection
2. finger clubbing
3. supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
4. chest signs consistent with lung cancer
5. thrombocytosis
129
What are 8 causes of restrictive pulmonary function tests?
1. pulmonary fibrosis
2. asbestosis
3. sarcoidosis
4. ARDS
5. infant respiratory distress syndrome
6. Kyphoscoliosis e.g. ankylosing spondylitis
7. neuromuscular disorders
8. severe obesity
130
What are 4 causes of obstructive lung function tests?
1. asthma
2. COPD
3. bronchiectasis
4. bronchiolitis obliterans
131
What antibiotic should be added to amoxicillin in CAP if staphylococci are suspected e.g. in influenza?
flucloxacillin
132
What type of organism is pneumocystic jiroveci?
unicellular eukaryote - generally classified as fungus but some consider it a protozoa
133
What is the most common opportunistic infection in AIDS?
PCP - pneumocystis jiroveci
134
What is a common complication of PCP pneumonia?
pneumothorax
135
What are 3 extrapulmonary manifestations in PCP pneumonia?
1. hepatosplenomegaly
2. lymphadenopathy
3. choroid lesions
136
What investigation is often needed to diagnose PCP?
bronchoalveolar lavage (BAL) - often sputum fails to show PCP
137
What is the management of PCP pneumonia?
* **co-trimoxazole**
* IV pentamidine in severe cases
* aerosolised pentamidine is alternative
* steroids if hypoxic
138
Which type of pneumonia is associated with erythema multiforme and erythema nodosum?
mycoplasma pnuemonia
139
What are the symptoms of mycoplasmia pneumonia?
prolonged and gradual onset, flu-like symptoms precede dry cough
140
What are 4 situations where oxygen therapy should not be used routinely if there is no evidence of hypoxia?
1. myocardial infarction and ACS
2. stroke
3. obstetric emergencies
4. anxiety-related hyperventilation
141
What are 4 features of pneumococcal pneumonia (e.g. Streptococcus pneumoniae)?
1. rapid onset
2. high fever
3. pleuritic chest pain
4. herpes labialis (cold sores)
142
What are 6 drugs that can cause lung fibrosis?
1. amiodarone
2. cytotoxic: busulphan, bleomycin
3. methotrexate
4. sulfasalazine
5. nitrofurantoin
6. dopamine receptor agonists: bromocriptine, cabergoline, pergolide
143
What is the best option for symptom control in non-CF bronchiectasis?
inspiratory muscle training + postural drainage
144
How should inhaled steroids be tapered down in well-controlled asthma?
reduce dose by 25-50%
145
How can you remember the side effects of bupropion / varenicline?
BEVD:
bupropion - CI epilepsy / eating disorder
varenicline - CI in depression
146
What are 9 complicatoins of mycoplasma pneumoniae?
1. **cold agglutins - can cause haemolytic anaemia, thrombocytopenia**
2. **erythema multiforme / erythema nodosum**
3. meningoencephalitis
4. GBS
5. bullous myringitis
6. pericarditis/ myocarditis
7. hepatitis
8. pancreatitis
9. acute glomerulonephritis
147
How is a diagnosis of mycoplasma pneumonia made?
mycoplasma serology
148
What will CXR show in mycoplasma pneumonia?
bilateral consolidation
149
How are cold agglutins detected in mycoplasma pneumonia?
peripheral blood smear may show red blood cell agglutination
150
What is the management of mycoplasma pneumonia?
doxycycline or macrolide e.g. clarithromycin
151
What will be seen on CXR in lung abscess?
fluid-filled space within an area of consolidation, air-fluid level
