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MRCP Part 1 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Chlamydia Psittaci

  1. Treatment (1st Line and 2nd Line)
  2. How does it Present ?
A

1st Line = Doxycycline
2nd Line = Macrolides

Severe Pneumonia + Headaches + Organomegaly + Failure to respond to PENICILLIN base Antibiotics

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2
Q

Cystic Fibrosis Gene and Mutation

A

Delta F508 Deletion in Long Arm of Chromosome 7

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3
Q

Organisms that Colonize Cystic Fibrosis Patients ?

A
  1. Staphylococcus Aureus
  2. Pseudomonas Aeruginosa
  3. Burkholderia cepacia
  4. Aspergillus
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4
Q
A

pH<7.2 - Indication for placement of chest tube in Pleural Effusion.

PH <7.35 - Indication for ventilation and intubation in Asthma.

PO2<7.3 - Indication for LTOT.

FEV1 <1.5 - Contraindication for lung cancer resection

PaO₂ < 9.3 kPa in PCP - add corticosteroids in Tx.

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5
Q

Cystic Fibrosis Treatment

A
  1. Chest Physio
  2. High Fat diet
  3. Minimize Contact with other CF patients
  4. Creon
  5. Lumacaftor (More CFTR) /Ivacaftor (Potentiate existing CFTR) (Orkambi)
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6
Q

Contraindication for Lung Transplant in Cystic Fibrosis

A

Burkholderia cepacia

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7
Q

What type of Ventilation in :

COPD with Acidosis ?
T1RF
T2RF

A

NIV
CPAP
BiPAP

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8
Q

Allergic BronchoPulmonary Aspergillosis

  1. Treatment
  2. Features
A
  1. Corticosteroids
  2. Raised IgE + Eosinophilia + Positive IgG precipitins
    (NOT as positive as in aspergilloma)

Recurrent Chest Infections and NOT RESPONDING TO ASTHMA TREATMENT

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9
Q

What is the X ray finding for ABPA ?

A

Fitting CXR - transient migratory pulmonary infiltrates

PROXIMAL Bronchiectasis

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10
Q

Panacinar vs Centri acinar in COPD
Aetiology

A

Centri-Acinar in Smokers and Coal Worker Pneumoconiosis

Panacinar - Alpha-1- Antitrypsin Deficiency

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11
Q

Causes of Bronchiectasis

A

‘A SICK AIRWAY’

Airway obstruction/ lesion

Sequestration

Infection/Inflammation

Cystic Fibrosis

Kartagener’ s Syndrome

ABPA

Immunodeficiencies(Hypogammaglobinemia,Myeloma,
Selective igA deficiency,Lymphoma )

William Campbell Syndrome

Aspiration

Yellow Nail Syndrome/Young Syndrome

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12
Q

Tram Track Sign on X ray defined as ?

A

Dilated Bronchi with Thickened Walls in the Lower Zone

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13
Q

Common Organism to colonize in CF

A

Psuedomonas in ADULTS
S.Aureus in CHILDREN

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14
Q

Most Common Organisms Colonizing Bronchiectasis patients

A
  1. Haemophilus influenzae
  2. Pseudomonas aeruginosa (Long History and PPI Use associated)
  3. Klebsiella spp.
  4. Streptococcus pneumoniae
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15
Q

Mnemonic for Upper Lobe Fibrosis

A

A TEA SHOP

ABPA

TB
Extrinsic Alveolar Alveolitis
AS

Sarcoidosis
Histiocytosis
Occupational (Silicosis and Berylliosis)
Coal Worker Pneumoconeosis

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16
Q

Mnemonic for Lower Lobe Fibrosis

A

IPAS-BM

Infection

A
Aspiration
Alpha 1 Antitrypsin
Asbestosis

S
Systemic Sclerosis
RA

Bronchiectasis

Medications - Busulfan Bleomycin Nitrofurantoin Hydralazine Methotrexate Amiodarone

or SCAR

Systemic Sclerosis
Cryptogenic Fibrosing Alveolitis (IPF)
Asbestosis
RA

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17
Q

Smoking Cessation

A

Varenicline - a nicotinic receptor partial agonist
Start 1 week before Target Stop Date

Start 1 week before Target to Stop Date and 12 weeks course (Only continued if stop attempted)

SELF HARM or SUICIDAL BEHAVIOR CONTRAINDICATED

Bupropion -
norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist

Start 1 to 2 weeks before Target Stop Date

Seizures Risk –> CONTRAINDICATED IN EPILEPSY

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18
Q

Smoking Cessation in Pregnancy

A

Varenicline and Bupropion CONTRAINDICATED

Give CBT and Motivational Interviewing

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19
Q

Meigs Syndrome Triad ?

A

Ascites + Pleural Effusion, + Benign Ovarian Tumor

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20
Q

Right Sided Pleural Pneumothorax + Menstruating Women Think What ?

A

Catamenial Pneumothorax

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21
Q

Mnemonic for Pleural Cavities

A

CAVITY

Cancer - Lung SCC

Autoimmune -
RA , Wagener’s Granulomatosis

Vascular - Bland and Septic Emboli

Infection - PTB, Pulmonary Abscess

Trauma - Pneumatocele

Youth -
Congenital Airway Malformations
Bronchogenic Cysts

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22
Q

Red Flags for Chest Drain insertion ?

A

Hemodynamic Compromise

Severe Hypoxia

Bilateral Pneumothorax

Underlying Lung Disease

> /50 with Significant Smoking History

Hemopneumothorax

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23
Q

Discharge Advice for Patients treated for Pneumothorax

A

Scuba Diving - NEVER unless B/L Pleurectomy + Normal CT and PFT

Flying - 1 week post check X ray

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24
Q

LTOT offered in COPD if ?

A

2 ABG showing PO2<7.3
3 weeks apart

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25
What type of Lung Cancer is Associated with Non Smokers ?
Adeno Carcinoma
26
Difference between Biopsy for EAA vs Sarcoidosis
EAA - Non Caseating Granuloma BUT LESS DENSE AND LESS DEFINED Sarcoidosis - Non Caseating Granuloma BUT MORE DENSE AND DEFINED
27
EAA 1. Pathophysiology 2. Radiological Findings 3. Clinical Progression 4. Treatment
1. Not IgE associated Not Eosinophilia Associated No Type 1 HSN Acute (Type 3) and Chronic (Type 4) vs ABPA (TYPE 2) 2. Upper / Middle Lobe Fibrosis Honey Combing Ground Glass 3. Fibrosis then Respiratory Failure then Hypoxemia 4. Avoidance Oral Glucocorticoids
28
Byssinosis What exposure ?
Cotton / Flax / Textile Monday Chest Tightness
29
Silo Fillers Lung What Exposure ?
Nitric Oxide from Grain Dust in Silos Type 1 HSN so Not EAA
30
When to give steroids in Sarcoidosis
Symptomatic + Stage II/III Hypercalcemia Ocular Neuro or Cardiac Involvement
31
In EAA Farmers Lung makes you have Emphysema (Obstructive Picture) but Bird Farmers Lung causes Fibrosis (Restrictive Picture)
So in EAA both Restrictive and Obstructive Picture can be seen REMEMBER THIS
32
Pleural Plaques in Asbestosis are BENIGN They increase risk of Pleural Effusion NOT MESOTHELIOMA
Remember this point
33
Inspiratory Capacity = ? Functional Residual Capacity = ? Residual Volume = ? Expiratory Reserve Volume (ERV) Reduced by What ? Vital Capacity = ? Total Lung Capacity = ?
Tidal Volume + Inpiratory Reserve Volume Expiratory Reserve Volume + Residual Volume FRC - ERV Obesity Inspiratory Capacity + ERV
34
Treatment for IPF
Pulmonary Rehabilitation Breathless on Exertion --> LTOT Vaccinate Pneumococcus and Influenza If FVC<50-80% = Antifibrinolytics
35
Radiological Findings
Stage 1: Lower zone lung opacification Stage 2: Ground glass Stage 3: Honeycomb
36
Causes of Exudative vs Transudative Pleural Effusion ?
Exudative Malignancy Pneumonia and Parapneumonic Effusions Pancreatitis Autoimmune ( RA Churgg Straus Pleurisy) Post MI Transudative CHF Cirrhosis Nephrotic Syndrome Peritoneal Dialysis PE Hypothyroidism
37
Lights Criteria
Exudative if 1 of Pleural LDH/ Serum LDH >0.6 Pleural Protein/Serum Protein >0.5 Pleural LDH >2/3rd upper limit of Serum LDH
38
Why does HAPE and HACE occur ?
HAPE - High Altitude Pulmonary Edema Uneven Pulmonary Vasoconstriction from Hypobaric Hypoxia HACE - High Altitude Cerebral Vasodilation
39
Treatment for HACE and HAPE
HAPE Descent and Oxygen Nifedipine , Dexamethasone, Acetazolamide PDE5i HACE Descent Dexamethasone
40
Acute Mountain Sickness Preventative and Treatment
Acetazolamide - Preventative by creating a primary metabolic acidosis and compensatory respiratory alkalosis --> improving RR Treatment is DESCENT
41
Where is NIV not indicated ?
Bronchiectasis (a Trial only at best) Limited by excessive secretions
42
Oxygen Dissociation Curve Mnemonic ?
Left Shift - We have LEFT the tissue behind (Cells hold onto Hb) Right Shift - Giving Oxygen to Tissues
43
Causes of Right and Left Shift in Oxygen Dissociation Curve
Right Shift (CADET) Raised PCO2 Raised Acid Raised 2,3-DPG Raised Temperature Left Shift Low (ABOVE 5) Hb F Met Hb Carboxyhemoglobin
44
Examples of Hemoglobin Structural Changes that make LEFT SHIFT
Changes to Heme Affinity - Hb Kempsey (β99 Asp→Asn) - INCREASED O2 Affinity Changes to Allosteric Regulators like 2,3-DPG - Hb Rainier (β145 Tyr→His) - INCREASED O2 Affinity by making Hb more sensitive to regulators HbS (Valine to Glutamate at C6)
45
Causes of Respiratory Alkalosis
Hyperventilation PE (+ REDUCED PaO2) Altitude Pregnancy CNS - Stoke Encephalitis SAH Salicylate Poisoning (Early Resp alkalosis --> Metabolic Acidosis)
46
What causes a Raised TLCO ? Watch Medicosis Video)
PELHAM for raised TLCO P ulmonary haemorrhage, polycythaemia E xercise L eft to Right shunts H yperkinetic states A sthma (Late Stage Neovascularization) M ale gender Reduced DLCO Reduced Perfusion Systolic HF Anaemia Pulmonary Embolism PAH (Narrowed) Systemic Sclerosis (Damage to Pulmonary Artery) ASBESTOSIS Decreased Perfusion INTRINSIC Restrictive Lung Disease Medications Emphysema
47
Dyspnea + Obstructive Pattern + RA = >
Bronchiolitis Obliterans
48
How does Bronchiolitis Obliterans Appear on CT
Centrilobular Nodules with Bronchial wall Thickening
49
Conditions with Raised KCO ?
KCO = TLCO / VA VA roughly is lung volume or effective lung volume in compared to normal healthy lungs) So Raised KCO means ether TLCO is increased or VA is reduced. In here, Raised KCO is pretty much poor lung volume (Low VA) ANK SPOND, Scoliosis, kyphosis = lung posture NM weakness (Also reduced effective lung volume) Lobectomy and pneumonectomy (again low lung volume). *TLCO also known as DLCO on the web. *KCO = DLCO/VA *VA = effective lung volume
50
ERV is low in which patients and why ?
Obese because of decreased chest wall compliance
51
OSA Treatment ?
Weight Loss CPAP If not tolerated Oral mandibular devices
52
OSA Acid Base Picture ?
Compensated Respiratory Acidosis
53
LTRA Side Effects ?
Unmasking Churgg Strauss Syndrome Hepatic and Neuropsychiatric
54
Poor Prognostic Factors for Sarcoidosis ?
Factors associated with poor prognosis insidious onset, symptoms > 6 months absence of erythema nodosum extrapulmonary manifestations: e.g. lupus pernio, splenomegaly CXR: stage III-IV features black African or African-Caribbean ethnicity PS - MOST Sarcoidosis resolves without treatment
55
Surgical Contraindication for NSCLC ?
Mediastinoscopy before CT TRO Mediastinal LN Surgical Contraindications 1. SVCO 2. Vocal Cord Paralysis 3. Tumor near Hilum 4. Malignant Pleural Effusion 5. FEV1<1.5 (<1.5 for Lobectomy and <2 for Pneumonectomy)
56
Cavitating Lesions Mnemonic
WAP RATS (Wet Ass Pussy RATS) Wegners, Abscess, PE RA, Aspergillosis, TB, SCC
57
Alpha 1 Antitrypsin Deficiency 1. MOA 2. Inheritance 3. Treatment
Serine protease inhibitor (serpin) --> Inhibit Neutrophil Elastase ---> Prevent Alveolar Breakdown Autosomal Recessive / Co-Dominant Chromosome 14 Alpha 1 Antitrypsin Concentrates Lung Volume Reduction Surgery
58
A1AT Deficiency Genotypes
alleles classified by their electrophoretic mobility - M for normal, S for slow, and Z for very slow normal: PiMM heterozygous: PiMZ evidence base is conflicting re: risk of emphsema however, if non-smoker low risk of developing emphsema but may pass on A1AT gene to children homozygous PiSS: 50% normal A1AT levels homozygous PiZZ: 10% normal A1AT levels
59
How does Sarcoidosis Cause Hypercalcemia
Macrophages activate 1 Alpha Hydroxylase --> Activated Vitamin D3 --> Increase Calcium Absorption via Intestine DCT
60
Cherry Red Lesion on Bronchoscopy THINK WHAT ?
Lung Carcinoid
61
Why give Corticosteroids in COPD ?
Reduce Frequency of Exacerbations
62
Isocyanates associated with which Cancer Polyvinyl Chloride ? Aromatic Amines ?
Squamous Cell Carcinoma Angiosarcoma of Liver Bladder Ca
63
Occupational Asthma Diagnostic Investigation
Serial Peak Flow at Home and Work
64
Most Common Chemical Associated with Occupational Asthma
Isocyanates
65
Squamous Cell Cancer
Most Common Cancer in UK Cavitates PTHrP HPOA and Clubbing Central
66
Sarcoidosis CXR Classification ?
Sarcoidosis CXR 1 = BHL 2 = BHL + infiltrates 3 = infiltrates 4 = fibrosis
67
Bronchiectasis and Bilateral Hilar Lymphadenopathy NOT caused by ????
Amyloidosis
68
B/L Hilar Lymphadenopathy Causes ?
Berylliosis Histoplasmosis Coccidioidomycosis
69
Subfertility + Recurrent Chest Infections + Quiet Heart Sounds ?
Kartagener Syndrome Do Sweat Test TRO Cystic Fibrosis (Absence of Vas Deferens - Normal Sperms but just less
70
PAH Diagnostic Criteria
Pulmonary Arterial Pressure >20
71
Primary Spontaneous Pneumothorax Management
OP Follow up every 2-4 days ambulatory
72
Secondary Spontaneous Pneumothorax Management
Inpatient OP Follow-up once stable in 2-4 weeks
73
Hertford Syndrome Triad Lofgren Syndrome Triad
CHRONIC Fever + Triad of 1. Parotitis 2. Anterior Uveitis 3. Facial Palsy ACUTE Fever + Triad of 1. Erythema Nodosum 2. Migratory Polyarthritis 3. B/L Hilar Lymphadenopathy
74
Jüngling's disease what is it ?
Chronic Sarcoidosis with Cystic Bony Lesions in Acral Region (Fingers)
75
Mnemonic for Occupational Asthma Chemicals ?
GF works at PEPSI factory and comes home daily with Asthma symptoms GF— Glutaraldehyede. Flour PEPSi : Platinum salt Epoxy resins Proteolytic enzymes Soldering flux resins Isocyanates
76
Mat Worker Lung Organism Mushroom Worker Lung Farmers Lung
Aspergillus clavatus Thermophilic actinomycetes Saccharopolyspora rectivirgula
77
Is Coal Dust Associated with Lung Cancer ?
NO !
78
Do we need follow-up for Pleural Plaques on CXR ?
NO they aren't premalignant
79
Cystic Fibrosis Features
short stature DM delayed puberty rectal prolapse (due to bulky stools) nasal polyps male infertility, female subfertility
80
ARDS Diagnostic Criteria
2012 Berlin definition: remember as ABCD A: Acute onset (within 1 week of lung injury) B: bilaterafl infiltrates on CXR C: (not) cardiogenic D: Decreased PaO2:FiO2 (mild <300, mod <200, severe <100) HYPOXIC despite Oxygenation
81
Mechanism of Action of LTRA
Binds to CysLT1 Receptors Blocking action of cysteinyl leukotrienes in Bronchial Tissue which are released by Immune System to increase mucus secretion, bronchoconstriction etc ...
82
Investigation of Choice for Fixed Upper Airway (Tumor, Goiter etc... )
Flow - Volume Loops
83
Asthma workup (New Guidelines) for >16
1. Eosinophilia or FeNO (>40ppb) 2. BDR (FEV1>12% or 200mls Pre and Post BD OR >10% of Predicted) If Unavailable then PEFR 3.Twice Daily for 2 weeks (20% variability) 4. Bronchial Challenge Test If NO for BDR Test then Straight to Bronchial Challenge Test
84
Asthma Workup for 5-16 y/o
SAME as above but FeNO > 35ppb NO Eosinophilia 1, 2, 3 same but 4 is 4. Skin Prick for House Mite OR Total IgE raised If Yes --> Eosinophils >0.5*10^9 ? --> If NO then Refer for 2nd Opinion and Bronchial Challenge Test
85
Asthma Workup for <5y/o
Any Preschooler with 1 hospital admission OR >/= 2 ED admissions WITHIN 12 months

MRCP Part 1 (18 decks)

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