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1. MSRA CRAM > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Diagnostic testing for asthma

A

Patients >= 17 years
1. Patients should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma
2. All patients should have spirometry with a bronchodilator reversibility (BDR) test → a positive test is improvement in FEV1 of 12% or more and increase in volume of 200 ml or more (FEV1/FVC ratio <70% is considered obstructive)
3. All patients should have a FeNO test → In adults level of >= 40 parts per billion (ppb) is considered positive

Children 5-16 years
1. All children should have spirometry with a bronchodilator reversibility (BDR) test
2. A FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test

Patients < 5 years
1. Diagnosis should be made on clinical judgement

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2
Q

Management of chronic asthma

A

1) Short-acting beta agonist (SABA)
- For all new diagnosis of asthma
2) SABA + low-dose inhaled corticosteroid (ICS)
- If symptoms >= 3 / week or night-time waking
3) SABA + low-dose ICS + leukotriene receptor antagonist (LTRA - montelukast)
4) SABA + low-dose ICS + long-acting beta agonist (LABA - salmeterol, formoterol), continue LTRA depending on patient’s response to LTRA
5) SABA +/- LTRA, switch ICS/LABA for a maintenance and reliever therapy (MART), which is a combined ICS and LABA
6) SABA +/- LTRA + medium-dose ICS MART OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
7) SABA +/- LTRA + one of the following options:
- Increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART)
- A trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline)
- Seeking advice from a healthcare professional with expertise in asthma

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3
Q

Management for occupational asthma

A

Refer to a specialist

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4
Q

Investigations for COPD

A
  1. Post-bronchodilator spirometry: FEV1/FVC ratio less than 70% shows airflow obstruction
  2. Chest x-ray: hyperinflation
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5
Q

Management of chronic COPD

A
  1. Smoking cessation
  2. First step: a short-acting beta2-agonist (SABA - salbutamol) OR short-acting muscarinic antagonist (SAMA - ipratropium)
    …
  3. Second step: IF steroid-responsiveness/ features/ previous asthma or atopy/higher blood eosinophil count: Long-acting beta agonists (LABA - salmeterol) + inhaled corticosteroid (ICS - beclometasone)
    IF NOT then: LABA + LAMA
    …
  4. Third step: If ongoing symptoms, offer triple therapy i.e. LAMA + LABA + ICS (if already taking a SAMA, discontinue and switch to a SABA)
    …
    (LAMA and a SAMA together can lead to excessive anticholinergic effects, increasing the risk of dry mouth, urinary retention, constipation, and blurred vision.)
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6
Q

Indications for LTOT in COPD

A

LTOT is offered to patients who do not smoke AND:
PaO2 < 7.3 kPa when stable
OR
PaO2 7.3 < PaO2 < 8 kPa when stable AND
1. Secondary polycythaemia
2. Peripheral oedema
3. Pulmonary hypertension

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7
Q

In what situations would a patient with acute bronchitis receive antibiotics?

A
  1. Systemically very unwell patients
  2. Patients with pre-existing co-morbidities
  3. CRP of 20-100mg/L (offer delayed prescription)
  4. CRP >100mg/L (offer antibiotics immediately)
    …
    (1st choice is oral doxycycline: 200 mg on the first day, then 100 mg once a day for 4 days)
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8
Q

Causing organisms of pneumonia

A
  1. Streptococcus pneumoniae: most common cause of CAP
  2. Staphylococcus aureus: most common cause of HAP, following influenza infection,
  3. Haemophilus influenzae: patients with COPD
  4. Mycoplasma pneumoniae: dry cough, cold autoimmune haemolytic anaemia, erythema multiforme, bullous myringitis and atypical chest signs/x-ray findings; Rx macrolide
  5. Legionella pneumophilia: to infected air conditioning units, confusion, hyponatraeia, lymphopenia; Rx macrolide
  6. Klebsiella pneumoniae: classically seen in alcoholics
  7. Pneumocystis jiroveci: typically seen in patients with HIV; Rx co-trimoxazole
  8. Chlamydia psittaci: a cause of pneumonia in bird keepers
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9
Q

How is latent tuberculosis (TB) screened for?

A

Mantoux test

(consists of an intradermal injection of PPD tuberculin; a person who has been exposed to the bacteria is expected to mount an immune response in the skin containing the bacterial proteins)

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10
Q

What investigations are done for active tuberculosis (TB)?

A
  1. Chest x-ray (upper lobe cavitation is the classical finding of reactivated TB; also bilateral hilar lymphadenopathy)
  2. Sputum smear (3 specimens are needed and are stained for the presence of acid-fast bacilli using Ziehl-Neelsen stain)
  3. Sputum culture for definitive diagnosis (the gold standard investigation but can take 1-3 weeks)
  4. Nucleic acid amplification tests (NAAT: allows rapid diagnosis within 24-48 hours; more sensitive than smear but less sensitive than culture)
  5. Offer HIV test for all patients with TB (because TB is classified as one of the ‘AIDS-defining’ illnesses seen in the UK and Europe and will guide management)
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11
Q

What is the management for latent tuberculosis (TB)?

A

3 months:

  1. Isoniazid (with pyridoxine)
  2. Rifampicin

OR

6 months:

Isoniazid (with pyridoxine)

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12
Q

What is the management for active tuberculosis (TB)?

A

Initial phase - 4 drugs for 2 months:

  1. Rifampicin
  2. Isoniazid
  3. Pyrazinamide
  4. Ethambutol

Continuation phase - 2 drugs for 4 months:

  1. Rifampicin
  2. Isoniazid
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13
Q

Make a note on adenocarcinoma of the lung

A
  1. Typically peripheral
  2. This is now the most common type of lung cancer
  3. Often seen in non-smokers
  4. Gynaecomastia
  5. Hypertrophic pulmonary osteoarthropathy (HPOA)
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14
Q

Make a note on squamous cell carcinoma of the lung

A
  1. Typically central
  2. Associated with parathyroid hormone-related protein (PTHrP) secretion → Hypercalcaemia
  3. Strongly associated with finger clubbing
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15
Q

Make a note on large cell carcinoma of the lung

A
  1. Typically peripheral
  2. Anaplastic, poorly differentiated tumours with a poor prognosis
  3. May secrete β-hCG
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16
Q

Make a note on small cell carcinoma of the lung

A
  1. Typically central
  2. Associated with ectopic ADH and ACTH secretion
  3. ADH → hyponatraemia
  4. ACTH → Cushing’s syndrome
  5. ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis
  6. Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome
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17
Q

What are the most common organisms isolated from patients with bronchiectasis?

A
  1. Haemophilus influenzae (most common)
  2. Pseudomonas aeruginosa
  3. Klebsiella spp.
  4. Streptococcus pneumoniae
18
Q

What investigations are done for bronchiectasis?

A

Main investigations:
1. Sputum culture and sensitivity (may show a pathogenic organism i.e. haemophilus influenzae)
2. Chest x-ray (shows tramlines and ring shadows)
2. High resolution CT scan of the thorax (best investigation, diagnostic: shows thickened, dilated bronchi: `signet ring’ sign)

Other investigations:

  • Serum immunoglobulins (low in those with immunoglobulin deficiences such as hypogammaglobulinaemia)
  • Chloride sweat test (abnormal test is diagnostic for cystic fibrosis)
  • Total IgE and Aspergillus precipitins (↑IgE in ABPA)
19
Q

Gold standard test for cystic fibrosis

A

Sweat test → Chloride > 60 mmol/L

20
Q

What is the most common inherited thrombophilia?

A

Factor V Leiden

21
Q

Investigation of pulmonary embolism Wells score 4 points or less (unlikely)

A

D-dimer test
…
- If positive arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give interim therapeutic anticoagulation until the scan is performed
- If negative then PE is unlikely - stop anticoagulation and consider an alternative diagnosis

22
Q

Investigation of pulmonary embolism Wells more than 4 points (likely)

A

Arrange an immediate computed tomography pulmonary angiogram (CTPA)
…
- If there is a delay in getting the CTPA then interim therapeutic anticoagulation should be given until the scan is performed
- If the CTPA is negative then consider a proximal leg vein ultrasound scan if DVT is suspected

23
Q

What is the management for pneumothorax?

A
  1. Primary pneumothorax ≤ 2cm and/or not breathless: Discharge
  2. Primary pneumothroax > 2cm and/or breathless: Needle aspiration via a cannula, 2nd intercostal space mid clavicular line: if successful then discharge; If not successful THEN chest drain in the 5th intercostal space mid axillary line (of the affected side)
  3. Secondary pneumothorax < 1cm: Admit, Give high flow O2, Observe for 24 hrs
  4. Secondary pneumothorax 1-2 cm: Needle aspiration via a cannula, 2nd intercostal space mid clavicular line: if successful then admit, high flow O2 and observe for 24 hrs; If not successful THEN chest drain in the 5th intercostal space mid axillary line (of the affected side)
  5. Secondary pneumothorax > 2 cm: Chest drain in the 5th intercostal space mid axillary line (of the affected side)
24
Q

What is the management for tension pneumothorax?

A
  1. Give O2
  2. Needle decompression via a cannula, 2nd intercostal space mid clavicular line (of the affected side)
  3. Chest drain in the 5th intercostal space mid axillary line
25
What is the management for lung abscess?
1. IV antibiotics 2. If not resolving percutaneous drainage may be required and in very rare cases surgical resection
26
For empyema: Turbid effusion with pH \_\_\_ \_\_\_ glucose \_\_\_ LDH
Turbid effusion with pH **_\< 7.2_** **_LOW_** glucose **_HIGH_** LDH
27
What is the management for empyema?
An empyema will heal only if infection is eradicated and the empyema space is obliterated: 1. Empirical antibiotic treatment: IV co-amoxiclav AND metronidazole (if the organism is unknown) 2. Chest drain: to remove of all the pus from the pleural space
28
List the transudative causes of a pleural effusion
Transudates (\<30g/L): 1. **_Heart failure_** (most common transudate cause) 2. Cirrhosis (liver failure) 3. Nephrotic syndrome (hypoalbuminaemia) 4. Hypothyroidism 5. Constrictive pericarditis 6. Meigs' syndrome (triad of benign ovarian tumour with ascites and pleural effusion that resolves after resection of the tumour) (increased hydrostatic pressure or decreased osmotic pressure)
29
List the exudative causes of a pleural effusion
Exudates (\>30g/L): 1. **_Pneumonia_** (most common exudate cause) 2. Tuberculosis 3. Lung cancer 4. Connective tissue disease: Rheumatoid arthritis, Systemic Lupus Erythematous 5. Pancreatitis 6. Pulmonary embolism (increased microvascular pressure due to disease of the pleura or injury in the adjacent lung)
30
What investigations do we do for a pleural effusion?
1. _Chest x-ray_ (200ml of fluid required in order to be seen) – loss of costophrenic angle, tracheal deviation for large effusion 2. Contrast enhanced _CT scan_ of the thorax – shows pleural thickening; indicated where malignant disease is suspected 3. _Ultrasound_ – useful for guiding aspiration as shows real time site marking 4. **_Diagnostic pleural aspiration/thoracentesis and biopsy_** (50ml syringe, 21G needle) and fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
31
What investigations do we do for a pleural effusion?
1. _Chest x-ray_ (200ml of fluid required in order to be seen) – loss of costophrenic angle, tracheal deviation for large effusion 2. Contrast enhanced _CT scan_ of the thorax – shows pleural thickening; indicated where malignant disease is suspected 3. _Ultrasound_ – useful for guiding aspiration as shows real time site marking 4. **_Diagnostic pleural aspiration/thoracentesis and biopsy_** (50ml syringe, 21G needle) and fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
32
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: 1. Effusion protein : serum protein ratio \> 0.5 2. Effusion LDH : serum LDH ratio \> 0.6 3. Effusion LDH \> 2/3 of the normal upper limit for serum LDH (LDH = lactate dehydrogenase)
33
What is the definitive test to diagnose obstructive sleep apnoea?
Polysomnography
34
The first choice therapy for patients with moderate or severe obstructive sleep apnoea
Continuous positive airway pressure (CPAP)
35
What are the causes of pulmonary fibrosis?
Upper zone (CARTEx): 1. **_C_**oal 2. **_A_**nkylosing spondylitis 3. **_R_**adiation 4. **_T_**uberculosis 5. **_Ex_**trinsic allergic alveolitis Lower zone (CAID: more common): 1. **_C_**onnective tissue disorders: rheumatoid, scleroderma 2. **_A_**sbestosis 3. **_I_**diopathic pulmonary fibrosis 4. **_D_**rugs: nitrofurantoin, amiodarone, methotrexate, bleomycin, cyclophosphamide, sulfasalazine
36
Drugs used in the management of idioapathic pulmonary fibrosis
Pirfenidone (an antifibrotic agent) OR Nintedanib (a tyrosine kinase inhibitor)
37
What are the indications for systemic corticosteroids in sarcoidosis?
1. Patients with CXR stage 2 or 3 disease AND symptomatic 2. Hypercalcaemia (macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)) 3. Eye, cardiac or neurological involvement
38
Hypersensitivity pneumonitis (Extrinsic allergic alveolitis) summary:
1. Farmer's/ bird fancier's lung 2. ↑Eosinophils 3. CXR: upper/mide zone fibrosis 4. Rx: Avoid exposure, steroids
39
Aspergillus summary:
1. ↑Eosinophils, ↑IgE, Positive RAST to aspergillus, Positive IgG precipitins 2. CXR: round opacity/ crescent sign 3. Rx: 1st line: Steroids; 2nd line: Itraconazole
40
Coal worker's pneumoconiosis summary:
1. Dust/ coal mines 2. CXR: upper zone fibrosis (round opacities) 3. Rx: Avoid exposure
41
Silicosis summary:
1. Inhalation of silica dust, mining workers 2. CXR: upper zone fibrosis (egg shell calcifcation of the hilar lymph nodes) 3. Rx: Avoid exposure

1. MSRA CRAM (12 decks)

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