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Respiratory Flashcards

1
Q

What is the typical presentation of sarcoidosis?

A

Can affect many different systems, e.g.
respiratory (SoB, dry cough, hoarse voice)
systemic (weight loss, malaise, fever, fatigue)
skin (erythema nodosum)
eyes (uveitis)
MSK (polyarthralgia)
CNS (seizures, facial palsy)
renal (hypercalcaemia, hypercalciuria)
cardiovascular (arrhythmias)

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2
Q

What is Lofgren’s syndrome?

A

acute form of sarcoidosis
triad: 1. arthralgia 2. erythema nodosum 3. hilar lymphadenopathy on CXR
absence of red flags!

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3
Q

What is sarcoidosis?

A

multi-system granulomatous disease
formation of non-caseating granulomas in organs

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4
Q

What is stage 1 of sarcoid?

A

hilar lymphadenopathy
likely to resolve spontaneously

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5
Q

what is stage 2 of sarcoid?

A

hilar lymphadenopathy + parenchymal involvement
likely to resolve spontaneously

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6
Q

what is stage 3 of sarcoid?

A

only parenchymal involvement (formation of reticular opacities)
likely to progress and require treatment

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7
Q

what is stage 4 of sarcoid?

A

pulmonary fibrosis
likely to progress and require treatment

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8
Q

what will CXR show in sarcoid?

A

hilar lymphadenopathy
diffuse infiltrates in lung fields

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9
Q

what blood tests are typical/diagnostic in sarcoidosis?

A

ACE levels - raised
Calcium - raised

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10
Q

what will biopsy of sarcoid show?

A

non-caseating granuloma with epithelioid cells

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11
Q

what is the management for sarcoid?

A

conservative management - asymptomatic/mild symptoms
oral steroids - 6-24 months
methotrexate

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12
Q

what is the indication for steroids in sarcoid?

A

PUNCH
Parenchymal Lung Disease
Uveitis
Neurological Involvement
Cardiac Involvement
Hypercalcaemia

CXR showing stage 2-3 and have symptoms (parenchymal lung disease)
hypercalcaemia
involvement of heart/eye/nervous system

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13
Q

what investigations are used for sarcoid?

A

CXR
spirometry - might be restrictive
tissue biopsy - non-caseating granulomas

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14
Q

what are the risk factors for sarcoid?

A

female
African descent
20-40 y.o.

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15
Q

What factors are associated with poorer prognosis in sarcoidosis?

A

African descent
insiduous onset
symptoms lasting for 6+ months
absence of erythema nodosum
extrapulmonary manifestations (lupus pernio, splenomegaly)
stage 3-4 features on CXR

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16
Q

What is bronchiectasis?

A

Chronic dilation of bronchi, leading to sputum collection and bacterial growth

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17
Q

What is yellow nail syndrome? I.e. what are the main signs?

A

Yellow nails, lymphoedema, and bronchiectasis

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18
Q

What respiratory condition is yellow nail syndrome associated with?

A

Bronchiectasis

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19
Q

What are some causes of bronchiectasis?

A

CICA TYP:
Cystic fibrosis
Idiopathic
Connective tissue disorders
Alpha 1 antitrypsin deficiency
Tuberculosis
Yellow nail syndrome
Pertussis

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20
Q

What are the key symptoms of bronchiectasis?

A

Chronic productive cough
Progressive SoB
Recurrent chest infections
Wheeze
Pleuritic chest pain
Red flag symptoms: Weight loss, fatigue, haemoptysis

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21
Q

What signs on examination can you find in patients with bronchiectasis?

A

Coarse bi-basal crackles
Finger clubbing
Cachexia
Signs of cor pulmonale
Scattered wheeze and crackles
Sputum pot
Oxygen therapy

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22
Q

What investigations should you do if you suspect bronchiectasis? And why?

A

Sputum culture - most common organisms are Haemophilus influenza, and Pseudomonas aeruginosa
CXR - tram track opacities, ring shadows
Bloods - FBC
Spirometry - assess severity of obstruction and identify any coexisting diagnoses
HRCT - best imaging - signet ring, dilated bronchi
Investigations to determine underlying cause,
e.g Tests for cystic fibrosis - e.g. sweat test
HIV serology
Immunoglobulin tests

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23
Q

What organisms can you most commonly find in sputum culture of a patient with bronchiectasis?

A

Haemophilus influenza
Pseudomonas aeruginosa

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24
Q

What will CXR show in bronchiectasis?

A

tram track opacities, ring shadows

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25
Q

what will HRCT show in bronchiectasis?

A

signet ring sign, dilatation of bronchi

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26
Q

What is the management of bronchiectasis?

A

physical training/pulmonary physiotherapy
bronchodilators (in some cases)
smoking cessation
vaccination
surgery (very rare - only if localised)

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27
Q

what are the potential complications of bronchiectasis?

A

exacerbations (deterioration in 3+ symptoms for 48+ hrs)
pneumonia
cor pulmonale
respiratory failure
recurrent pleurisy

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28
Q

What is interstitial lung disease?

A

umbrella term
inflammation and fibrosis of lung parenchyma

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29
Q

What are some types of interstitial lung disease?

A

Idiopathic pulmonary fibrosis
Cryptogenic organising pneumonia
Hypersensitivity pneumonitis
Asbestosis, silicosis
ILD of connective tissue dissease

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30
Q

What are the key presenting features of interstitial lung disease?

A

gradual SoB (esp. on exertion)
dry cough
fatigue

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31
Q

What examination findings will you find in idiopathic pulmonary fibrosis?

A

Bi-basal fine-end inspiratory crackles
finger clubbing

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32
Q

What are the risk factors for interstitial lung disease?

A

occupational exposure to asbestos, silica
bird keeper
IPF: male, smoker, older
CTD: younger, female, connective tissue disease
certain drugs (bleomycin - chemo; amiodarone - anti-arrhythmic; nitrofurantoin - ATB; methotrexate - anti-inflammatory)

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33
Q

How is interstitial lung disease/IPF diagnosed?

A

clinical features and Hx
HRCT - ground glass appearance -> honeycombing
spirometry - restrictive pattern or normal

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34
Q

What are the spirometry findings in patients with interstitial lung disease/IPF?

A

FEV1 normal or reduced
FVC can be reduced
FEV1/FVC normal or restrictive
transfer factor (TLCO) - reduced - impaired gas exchange

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35
Q

What is the gold standard imaging for idiopathic pulmonary fibrosis?

A

HRCT - ground glass/honeycombing

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36
Q

What is the management of interstitial lung disease?

A

if underlying cause - remove/treat
medications - steroids (if inflammatory cause), antifibrotics if fibrotic (pirfenidone, nintedanib)
hypoxia - o2 therapy
smoking cessation
pulmonary rehabilitation
vaccinations
advanced care planning, palliative care
lung transplantation

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37
Q

How is IPF managed?

A

pulmonary rehabilitation
anti-fibrotics - pirfenidone, nintedanib - to slow the progression
supplementary o2
lung transplantation

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38
Q

What is the prognosis of IPF?

A

poor - typically 3-4 years (can be a bit higher with treatment)

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39
Q

What drugs can cause ILD?

A

chemotherapy - bleomycin
anti-arrhythmic - amiodarone
ATBs (long-term) - nitrofurantoin
anti-inflammatory - methotrexate

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40
Q

What is asthma?

A

Chronic inflammatory airway disease secondary to type 1 hypersensitivity
Hypersensitive smooth muscle causes bronchospasm, leading to airway obstruction.
The bronchospasm is reversible with bronchodilators.
Symptoms are variable - diurnal variation

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41
Q

What are the main types of asthma? (onset)

A

childhood onset
adult onset
occupational asthma - flour, isocyanates

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42
Q

What are the risk factors for developing asthma?

A

Hx or Fx of atopy
low birth weight
maternal smoking, viral infections during pregnancy
respiratory infections in infancy
(parental) exposure to tobacco smoke
exposure to high concentrations of allergens
air pollution

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43
Q

What is the pathophysiology of asthma?

A

IgE antibodies sensitised and released by plasma cells in response to environmental triggers
IgE antibodies bind to mast cells - degranulation
Release of cytokines, histamine, prostaglandins and leukotriens -> leads to bronchospasm - airway obstruction
Th2 lymphocytes - production of interleukins -> sustain inflammation
Leads to airway hypersensitivity and hyper-responsiveness

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44
Q

What are some common triggers of asthma attacks/worsening of asthma symptoms?

A

Infection
Nighttime and early morning
Exercise
Animals
Some medications (non-selective beta blockers e.g. propranolol, NSAIDs e.g. aspirin)
Cold air
Strong emotions

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45
Q

How do patients with asthma typically present?

A

Dry cough, often worse at night
SoB
Wheeze
Chest pain/tightness
Diurnal variation in symptoms (worse in the morning and at night)
Reversibility with bronchodilators

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46
Q

What are examination finding in asthma?

A

Can be normal if between attacks
Widespread polyphonic expiratory wheeze (NOT monophonic!)

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47
Q

What could a localised monophonic wheeze suggest?

A

Inhaled foreign body
Tumour
Mucus plug

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48
Q

What investigations are used when you suspect asthma?

A

Spirometry with bronchodilator reversibility
Fractional exhaled nitric oxide FeNO
Peak flow variability
Direct bronchial challenge test (inhaled histamine)

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49
Q

What will spirometry show in ashtma?

A

Obstructive picture
FEV1 significantly reduced
FEV1/FVC < 70%

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50
Q

What will a positive reversibility test show in asthma?

A

Increase in FEV1 of 12% or more

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51
Q

What will a positive FeNO test show in asthma?

A

40 ppb or higher

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52
Q

Why is FeNO used in asthma diagnosis?

A

NO is a marker of airway inflammation

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53
Q

How is peak flow variability measured?

A

Keeping a peak flow diary with readings at least 2x a day
For 2-4 weeks

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54
Q

What is a positive peak flow variability?

A

If peak flow variability is more than 20%

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55
Q

What classes of drugs are used in asthma? Give 1 example for each

A

Short-acting beta agonists (SABA) - salbutamol
Inhaled corticosteroids (ICS) - beclomethasone
Long-acting beta agonists (LABA) - salmeterol
Leukotriene receptor antagonists - monteleukast
Long-acting muscurinic receptor antagonists (LAMA) - tiotropium
Maintenance and reliever therapy (MART) - combination of ICS and fast-acting LABA (formoterol)

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56
Q

How does SABA (and LABA) work?

A

Adrenalin binds to beta 2 adrenergic receptors on smooth muscle in the airway. This leads to relaxation of the smooth muscle and bronchodilation.
SABA and LABA stimulate the same receptor and cause bronchodilation.

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57
Q

How does LAMA work?

A

block acetylcholine receptors, preventing contraction of bronchial smooth muscle, and leading to bronchodilation

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58
Q

Which medications aim to reduce the inflammation in the airways in asthma?

A

Inhaled corticosteroids (ICS) - e.g. beclomethasone
Leukotriene receptor antagonists - e.g. monteleukast
Theophylline - also caused bronchodilation

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59
Q

What is step 1 in asthma management?

A

SABA

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60
Q

What is step 2 in asthma management? When do you step up from step 1?

A

When not controlled on step 1 (symptoms 3+ times a week) OR new asthma with symptoms more than 3 times a week
SABA + ICS

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61
Q

What is step 3 in asthma management?

A

SABA + ICS + leukotriene receptor antagonist

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62
Q

What is step 4 in asthma management?

A

SABA + ICS + LABA (+/- LTRA - based on the response to LTRA)

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63
Q

What is step 5 in asthma management?

A

SABA + low-dose ICS MART (+/- LTRA)

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64
Q

What is step 6 in asthma management?

A

SABA + medium-dose ICS MART (+/- LTRA)

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65
Q

What is step 7 (final) in asthma management?

A

SABA +/- LTRA and either of the following:
- high-dose ICS (fixed dose, not MART)
- trial of an additional drug - e.g. LAMA (tiotropium), theophylline
- specialist management

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66
Q

What are the additional management recommendations in asthma?

A

individual self-management plan
yearly flu vaccination
yearly asthma review
regular exercise
avoid smoking
avoid triggers when possible

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67
Q

What are the three stages of acute asthma?

A

Moderate
Severe
Life-threatening

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68
Q

What are the features of acute asthma?

A

Progressive SoB
Use of accessory muscles
Tachypnoea
Cough
symptoms not improving with salbutamol
Symmetrical expiratory wheeze
Reduced air entry on auscultation

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69
Q

What are the features of moderate acute asthma?

A

PEFR of 50-75% best or predicted
able to complete sentences
RR < 25
HR < 110

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70
Q

What are the features of severe acute asthma?

A

PEFR of 33-50% best or predicted
unable to complete sentences
RR > 25
HR > 110

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71
Q

What are the features of life-threatening acute asthma?

A

PEFR of <33% best or predicted
O2 saturation <92%
Becoming fatigued
Absence of wheeze / silent chest
Cyanosis
Signs of shock
Confusion, agitation
Normal pCO2

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72
Q

What will ABG show initially in acute asthma?

A

respiratory alkalosis - hyperventilation will decrease pCO2

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73
Q

Why is respiratory acidosis a bad sign in acute asthma?

A

it means the pCO2 is high - patient very fatigued, almost stopping breathing

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74
Q

How is mild asthma exacerbation managed?

A

inhaled SABA via a spacer
quadrupled dose of ICS for up to 4 weeks
oral steroids (e.g. prednisolone) if ICS not adequate
ATB - if evidence of bacterial infection
follow-up within 48 hrs

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75
Q

How should moderate acute asthma be managed?

A

Hospital admission
Nebulised SABA
Steroids - oral prednisolone, IV hydrocortisone

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76
Q

How should severe exacerbation of asthma be managed?

A

Hospital admission
Oxygen to maintain pO2 >94%
salbutamol nebuliser
Nebulised ipratropium bromide
IV magnesium sulphate
IV salbutamol
IV aminophylline

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77
Q

How should life-threatening astma be managed?

A

“Oh Shit I Have Mad Asthma”
Hospital admission
Oxygen to maintain pO2 >94%
salbutamol nebuliser
Nebulised ipratropium bromide
IV magnesium sulphate
IV salbutamol
IV aminophylline
HDU/ICU admission
intubation and ventilation

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78
Q

What are criteria for discharge after an acute exacerbation of asthma?

A

stable on discharge medication (e.g. no oxygen, no nebulisers) for 12-24 hrs
checked and recorded inhaler technique
PEFR > 75% best or predicted

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79
Q

What do you need to monitor when administering IV salbutamol and why?

A

serum potassium - IV salbutamol can cause hypokalaemia as it promotes absorption of potassium from blood into cells

80
Q

What is the management/follow up after an acute asthma exacerbation?

A

optimising long-term asthma management
individual self-management plan
rescue pack of oral steroids
specialist referral if 2 attacks in 12 months

81
Q

What is obstructive lung disease? What are the findings on spirometry?

A

Asthma, COPD, bronchiectasis
FEV1 significantly reduced
FVC reduced or normal
FEV1/FVC - reduced

82
Q

What is restrictive lung disease? What are the findings on spirometry?

A

pumonary fibrosis, obesity, asbestosis
FEV1 reduced
FVC significantly reduced
FEV1/FVC - normal or increased

83
Q

What is COPD?

A

long-term respiratory condition involving airway obstruction, chronic bronchitis and emphysema

84
Q

What are the common features of COPD?

A

productive cough
SoB
wheeze
signs of cor pulmonale can be seen
recurrent respiratory infections
winter exacerbations

85
Q

What are some of the common signs of COPD?

A

tar staining
chest hyper-inflation
pursed lip breathing
use of accessory muscles of respiration
peripheral oedema
wheeze
crackles

86
Q

What are the risk factors for COPD?

A

smoker / passive smoking
40+ y.o.
male
cannabis (COPD at younger age)
alpha 1 antitrypsin deficiency

87
Q

What is Alpha-1 antitrypsin deficiency?

A

Inherited condition caused by a lack of protease inhibitor (produced by liver)
Protease inhibitor protects cells from elastase.
A1AT causes COPD in young non-smokers

88
Q

What are some features of A1AT?

A

symptoms of COPD
abnormal LFTs - liver cirrhosis, hepatocellular carcinoma, cholestasis

89
Q

What is Grade 1 on MRC Dyspnoea Scale?

A

SoB on strenuous exercise

90
Q

What is Grade 2 on MRC Dyspnoea Scale?

A

SoB when walking uphill

91
Q

What is Grade 3 on MRC Dyspnoea Scale?

A

SoB that slows walking on flat ground

92
Q

What is Grade 4 on MRC Dyspnoea scale?

A

SoB stops them from walking more than 100m on flat ground

93
Q

What is Grade 5 on MRC Dyspnoea Scale?

A

Too SoB to leave the house

94
Q

What investigations are recommended in suspected COPD?

A

post-bronchodilator spirometry showing obstructive picture (FEV1/FVC <70%)
CXR
FBC - exclude secondary polycythaemia
BMI
CT thorax
alpha 1 antitrypsin - if young and non-smoker
ECG, echo - assess for cor pulmonale
TLCO - reduced

95
Q

What will CXR show in COPD?

A

lung hyperinflation
bullous emphysema
flat hemidiaphragm
smaller heart size
horizontal ribs

96
Q

What is Stage 1 COPD? What is the FEV1?

A

Mild - FEV1 > 80% predicted

97
Q

What is Stage 2 COPD? What is the FEV1?

A

Moderate - FEV1 50-79% predicted

98
Q

What is Stage 3 COPD? What is the FEV1?

A

Severe - FEV1 30-49% predicted

99
Q

What is Stage 4 COPD? What is the FEV1?

A

Very severe - FEV < 30%

100
Q

What is the gold standard investigation for COPD diagnosis?

A

spirometry post-bronchodilator

101
Q

What is the long-term non-pharmacological management of COPD?

A
  • smoking cessation
  • annual vaccinations - influenza, pneumococcal
  • physiotherapy, pulmonary rehabilitation
102
Q

What smoking cessation drugs can be offered to COPD patients?

A

nicotine replacement therapy
varenicline - nicotinic partial agonist
bupropion - atypical antidepressant

103
Q

What is step 1 in COPD treatment? Give examples of drugs

A

SABA (salbutamol) or SAMA (ipratropium)

104
Q

How do you determine whether a COPD patient has asthmatic features?

A

Hx of asthma or atopy
increased eosinophil count
significant variation in FEV1 over time (>400ml)
significant diurnal variation in peak expiratory flow (>20%)

105
Q

What is step 2 in COPD treatment in patients with asthmatic features?

A

SABA/SAMA as required
LABA + ICS combination - Symbicord, Seretide

106
Q

What is an example of LABA + ICS combination inhaler?

A

Symbicord, Seretide, Fostair

107
Q

What is step 2 in COPD treatment in patients without asthmatic features?

A

SABA as required (switch to SABA if on SAMA)
LABA + LAMA combination - Anoro Ellipta, DuaKlir Genuair

108
Q

What is an example of LABA?

A

salmeterol, formoterol

109
Q

What is an example of LAMA?

A

tiotropium, glycopyrronium

110
Q

What is an example of SAMA?

A

ipratropium

111
Q

What is step 3 (final) in inhaler therapy of COPD?

A

SABA as required (if using SAMA - switch to SABA)
combination of LAMA + LABA + ICS - Trimbow, Trellegy Ellipta, Trixeo

112
Q

What is an example of combination of LAMA + LABA + ICS?

A

Trimbow, Trellegy Ellipta, Trixeo

113
Q

What are some oral add-ons to COPD therapy?

A

theophylline
carbocysteine - mucolytic
corticosteroids - prednisolone
ATBs - azithromycin
PDE-4 inhibitor - e.g. roflumilast

114
Q

What is the “rescue pack” in COPD?

A

short course of oral corticosteroids and antibiotics
offered if 1> exacerbation in the last year

115
Q

What is important to do before and during treatment with azithromycin?

A

ECG - to rule out QT prolongation
LFTs - to assess liver function

116
Q

When is long-term oxygen therapy offered to COPD patients?

A
  • chronic hypoxia (<92% / 7.3 on air) - on 2 separate occasions
  • secondary polycythaemia
  • cyanosis
  • cor pulmonale
117
Q

What medication should be used in patients with cor pulmonale?

A

loop diuretics - e.g. furosemide

118
Q

What are the most common infective causes of COPD exacerbation?

A

Bacterial - Haemophilus influenzae, Streptococcus pneumoniae
Viral - human rhinovirus

119
Q

What are the features of acute COPD exacerbation?

A

choryzal symptoms
increase in SoB, cough, wheeze
increase in sputum - infective

120
Q

What are the investigations in suspected acute COPD exacerbation?

A

CXR
gas exchange assessment
ECG
bloods
sputum culture

121
Q

How do you manage acute COPD exacerbation?

A

if hypoxic - O2 therapy
- nebulised bronchodilator - salbutamol, ipratropium
- oral corticosteroids (prednisolone 30mg daily for 5 days)
- ATB - if positive sputum culture - amoxicillin, clarithromycin, doxycycline

122
Q

What is the name, dose and duration of oral corticosteroids in acute COPD exacerbation?

A

prednisolone - 30mg once daily for 5 days

123
Q

What additional treatment can you use in acute COPD exacerbation in secondary care?

A
  • O2
  • IV theophylline - if not responding to nebulised bronchodilators
  • IV hydrocortisone (sometimes used instead of oral prednisolone)
  • intubation and ventilation
124
Q

When would you consider non-invasive ventilation?

A
  • persistant respiratory acidosis despite maximal medical treatment
  • potential to recover
  • acceptable to the patient
125
Q

What would raised bicarbonate on ABG suggest in a COPD patient?

A

chronic retention of CO2

126
Q

What is the most common cause of pneumonia? What are other possible causes?

A

Bacterial is most common
Other causes include viral and fungal (e.g. Pneumocystis jirovecii)

127
Q

What are the most common causative organisms of pneumonia?

A

Streptococcus pneumoniae
Klebsiella pneumoniae
Staphylococcus aureus
Haemophilus influenzae

128
Q

What are some atypical causative organisms of pneumonia?

A

Mycoplasma pneumoniae
Legionella pneumophilia
Pneumocystis jirovecii

129
Q

Which organism is typically seen in HIV patients presenting with pneumonia?

A

Pneumocystis jirovecii

130
Q

Which organism is typically seen in COPD patients presenting with pneumonia?

A

Haemophilus influenzae

131
Q

What is the typical presentation of pneumonia?

A

productive cough
haemoptysis
sputum production
SoB
chest pain (pleuritic)
fever
confusion

132
Q

What are some examination signs of pneumonia?

A

systemic signs of inflammation - fever, tachycardia
reduced oxygen saturation
reduced breath sounds
bronchial breathing
dullness to percussion
focal coarse crackles

133
Q

What investigations would you do if you suspect pneumonia?? And what results would you expect?

A

CXR - consolidation
FBC - neutrophilia
U&E - urea
CRP - raised
sputum cultures

ABG - if low O2 sats

134
Q

What is the basic management of pneumonia?

A

antibiotics
IV fluids if dehydrated
O2 therapy if hypoxic

135
Q

What scoring tool is used to assess severity of pneumonia in primary care?

A

CRB65
Confusion
Resp rate > 30
Blood pressure (systolic < 90 / diastolic < 60)
65+ y.o.

136
Q

How is CRB65 used to stratify the risk?

A

Score 0: low risk - treatment at home
Score 1-2: intermediate risk (1-10% mortality risk) - consider hospital assessment
Score 3-4: high risk (10%+ mortality risk) - urgent hospital admission

137
Q

What scoring tool is used to assess severity of pneumonia in secondary care?

A

CURB65
Confusion
Urea > 7mmol/L
Resp rate > 30
Blood pressure (systolic < 90 / diastolic < 60)
65+ y.o.

138
Q

How is CURB65 used to stratify the risk?

A

Score 0-1: low risk - treatment at home
Score 2+: intermediate risk (3-15% mortality risk) - hospital-based care
Score 3+: high risk (15%+ mortality risk) - intensive care assessment

139
Q

What is the management for low-severity CAP? (Medication)

A

5 day course of ATB
amoxicillin (macrolide or tetracycline if allergy)

140
Q

What is the management of moderate and high severity pneumonia? (pharmaceutical)

A

dual ATB therapy - amoxicillin and macrolide
7-10 day course

141
Q

What is hospital acquired pneumonia?

A

pneumonia that develops after more than 48 hours in a hospital

142
Q

What will sputum culture of someone with tuberculosis show?

A

acid-fast bacilli that stain red with Zeihl-Neelsen stain

143
Q

What can happen once M.tuberculosis is in the body?

A
  1. immediate clearance of the bacteria
  2. Primary active tuberculosis - active infection after exposure
  3. Latent tuberculosis - presence of bacteria without being infectious or symptomatic
  4. Secondary tuberculosis - reactivation of latent tuberculosis, usually due to immunosuppression
144
Q

What is miliary tuberculosis?

A

disseminated and severe form of active tuberculosis

145
Q

What are the risk factors for tuberculosis?

A

close contact with active tuberculosis
immigration from area with high TB prevalence
immunocompromised - HIV, immunosuppressant medications
malnutrition
homeless
drugs

146
Q

What is the Mantoux test?

A

injection of tuberculin (collection of TB proteins) into intradermal space on the forearm
Test is read after 72 hrs
Positive - induration of 5+mm

147
Q

How does tuberculosis typically present?

A

symptoms are usually chronic and gradually worsening
cough
haemoptysis
lethargy
fever
night sweats
weight loss
lymphadenopathy
erythema nodosum
cold abscess (in the neck)
spinal pain

148
Q

What is the typical onset and progression of TB symptoms?

A

symptoms are usually chronic and gradually worsening

149
Q

What is pleuritic chest pain?

A

worse when inhaling/breathing

150
Q

What is pneumothorax?

A

air entering the pleural space, separating the lung from the chest wall

151
Q

Tall, thin young male presents with sudden SoB and pleuritic chest pain. What is the likely cause?

A

pneumothorax

152
Q

What is the classification of pneumothoraces based on the cause?

A

Spontaneous (primary and secondary)
Trauma
Iatrogenic (e.g. due to lung biopsy, mechanical ventilation or central line insertion)

153
Q

What is primary spontaneous pneumothorax?

A

without underlying lung disease, often in tall, thin, young individuals
associated with the rupture of subpleural blebs or bullae

154
Q

What is secondary spontaneous pneumothorax?

A

in patients with pre-existing lung disease, such as COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia
certain connective tissue diseases such as Marfan’s syndrome are also a risk factor

155
Q

What are the main signs and symptoms of pneumothorax? (Hx and exam findings)

A

SoB
(pleuritic) chest pain
hyper-resonant on percussion
reduced breath sounds
reduced lung expansion
tachypnoea
tachycardia

156
Q

What are some additional signs and symptoms of a tension pneumothorax?

A

respiratory distress
tracheal deviation away from the side of the pneumothorax
hypotension

157
Q

What is the management of tension pneumothorax?

A

needle thoracostomy - inserting a cannula into the second intercostal space in the midclavicular line on the affected side
followed by the placement of a chest drain (tube thoracostomy) in the safe triangle of the chest

158
Q

How are patients with pneumothorax with no or minimal symptoms managed?

A

conservative management

159
Q

What are “high risk” characteristics in pneumothorax?

A

haemodynamic compromise (suggests tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
haemothorax

160
Q

How are patients with pneumothorax with high-risk characteristics managed?

A

if safe to intervene -> chest drain

161
Q

How are patients with pneumothorax without high-risk characteristics managed?

A

if not safe to intervene -> conservative management
if safe to intervene -> depends on patient’s main priority:

if procedure avoidance: conservative care
if rapid symptom relief as outpatient: pleural vent ambulatory device
if rapid symptom relief with short-term drainage: needle aspiration / chest drain

162
Q

What is pleural vent ambulatory device?

A

catheter inserted into the pleural space attached to a device stuck to the upper chest
allows air to exit, but not to enter
patient can wear it as an outpatient until the pneumothorax has resolved

163
Q

What is the triangle of safety? What are the borders?

A

place where chest drains are inserted

5th intercostal space (or the inferior nipple line)
Midaxillary line (or the lateral edge of the latissimus dorsi)
Anterior axillary line (or the lateral edge of the pectoralis major)

164
Q

How do you know a chest drain for pneumothorax is working?

A

bubbling (will disappear when pneumothorax resolves)
swinging of the water in the drain with respiration
CXR - to check positioning

165
Q

What are the two main complications of chest drains?

A

air leaks around the drain site
surgical emphysema

166
Q

When is surgical management required in patients with pneumothorax?

A

if chest drain fails to correct the pneumothorax
if there is a persistent air leak in the drain
if it’s a recurrent pneumothorax

167
Q

What is the surgical procedure to correct a pneumothorax?

A

VATS - video assisted thoracoscopic surgery
- abrasive pleurodesis - direct physical irritation of pleura
- chemical pleurodesis - using chemicals to irritate the pleura
- pleurectomy - removal of pleura

168
Q

What is pleurodesis? Why is it performed?

A

creating an inflammatory reaction in the pleural lining so the pleura sticks together and the pleural space becomes sealed
prevents further pneumothoraces from developing.

169
Q

What organism does commonly cause pneumonia with upper lobe cavitations, and is more common in diabetics and alcoholics?

A

klebsiella pneumoniae

170
Q

What is pulmonary hypertension?

A

increased resistance and pressure in the pulmonary arteries
mean pulmonary arterial pressure > 20mmHg

171
Q

What is the complication of pulmonary hypertension?

A

causes right sided heart strain - back pressure into the venous system

172
Q

What are the causes of pulmonary hypertension?

A

idiopathic / connective tissue disease
left heart failure - due to MI/systemic HTN
chronic lung disease - e.g. COPD
pulmonary vascular disease - e.g. PE
others - e.g. sarcoidosis

173
Q

What are the signs and symptoms of pulmonary hypertension?

A

SoB
syncope
tachycardia
raised JVP
hepatomegaly
peripheral oedema

174
Q

How is pulmonary hypertension investigated?

A

ECG - shows signs of right heart strain
CXR
raised NT-proBNP
echocardiogram

175
Q

What will ECG show in pulmonary hypertension?

A

signs of right sided heart strain:
- P pulmonale (peaked P waves)
- RV hypertrophy (tall R in V1,2 ; deep S in V5,6)
- R axis deviation
- R bundle branch block

176
Q

What will CXR show in pulmonary hypertension?

A

dilated pulmonary arteries
RV hypertrophy

177
Q

What is the prognosis in idiopathic pulmonary hypertension?

A

2-3 years after diagnosis if untreated

178
Q

How is idiopathic pulmonary hypertension treated?

A

Calcium channel blockers
Intravenous prostaglandins (e.g., epoprostenol)
Endothelin receptor antagonists (e.g., macitentan)
Phosphodiesterase-5 inhibitors (e.g., sildenafil)

179
Q

How is secondary pulmonary hypertension managed?

A

treating the cause
supportive treatments - oxygen therapy, diuretics

180
Q

If needle aspiration of pneumothorax is unsuccessful, what is the next step?

A

chest drain

181
Q

What is CPAP? When is it used?

A

Continuous positive airway pressure
treatment for obstructive sleep apnoea

182
Q

What is BiPAP? When is it used?

A

Bilevel positive airway pressure
form of non-invasive ventilation

183
Q

What are the causes of upper zone lung fibrosis?

A

CHARTS

C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
184
Q

What smoking cessation therapy is appropriate in pregnant women? Which is contraindicated?

A

appropriate - nicotine replacement therapy
contraindicated - varenicline, bupropion

185
Q

What is allergic bronchopulmonary aspergillosis?

A

result of allergy to Aspergillus spores
can have Hx of bronchiectasis and eosinophilia

186
Q

What are the features of allergic bronchopulmonary aspergillosis?

A

bronchoconstriction - wheeze, cough, dyspnoea, possible Hx of asthma
(proximal) bronchiectasis

187
Q

What will investigations show in allergic bronchopulmonary aspergillosis?

A

eosinophilia
CXR changes
positive RAST test to Aspergillus
positive IgG precipitins
raised IgE

188
Q

How is allergic bronchopulmonary aspergillosis managed?

A

oral glucocorticoids
second-line - itraconazole (antifungal)

189
Q

What are some predisposing factors for obstructive sleep apnoea?

A

obesity
macroglossia - acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s

190
Q

What are some features of obstructive sleep apnoea?

A

excessive snoring
periods of apnoea
results in:
daytime somnolence
compensated respiratory acidosis
HTN

191
Q

What are the diagnostic tests for obstructive sleep apnoea?

A

sleep studies (polysomnography) - ECG, respiratory airflow, thoraco-abdominal movement, snoring, pulse oximetry

192
Q

How is obstructive sleep apnoea managed?

A

weight loss
CPAP
intra-oral devices (e.g. mandibular advancement) - if not tolerating CPAP, no daytime sleepiness
inform DVLA if severe daytime sleepiness

193
Q

What is silicosis?

A

type of interstitial (fibrosing) lung disease
due to inhalation of silica
risk factor for TB

194
Q

What are the risk factors for silicosis?

A

occupational exposures:
mining
slate works
foundries
pottery

195
Q

What are the features of silicosis?

A

symptoms of fibrosis
upper zone fibrosing lung disease on CXR
egg-shell calcification of hilar lymph nodes on CXR

196
Q

What follow up should be organised for patients with pneumonia? and when?

A

CXR 6 weeks after resolution

197
Q
A

Y3 (11 decks)

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