Respiratory Flashcards
1
Q
What are common organisms of community acquired pneumonia?
Who are most at risk?
What are the gram stains and shapes?
What is the general abx options?
A
Streptococcus pneumoniae - elderly - gram pos cocci
Haemophillus influenza - copd - gram neg coccobacilus
Klebsiella pneumoniae - gram neg bacilli
Tx with amoxicillin or doxycyclin
2
Q
What are the commonest organisms for hospital aquired pneumonia?
What are the gram stains and shapes?
What is the general abx options?
A
Gram -ve enterococci - gram -ve cocci
Psudomonas aeruginosa - gram -ve bacillus
Staphylococcus aureus - gram +ve cocci
Ampicillin, ceftriaxone, OR merapenem, pipicillin (if ?MDR)
3
Q
When dose staphylococcus aureus usually cause pneumonia?
A
In patient with viral chest infection.
4
Q
What viruses may cause pneumonia?
A
Influenza
Parainfluenza
Respiratory syncytial virus
5
Q
What opportunistic infections cause pneumonia?
A
HSV CMV Candidia Aspergillus Pneumocystis jirovecii
6
Q
What are causes of atypical pneumonia with type, gram and risk factor
A
Clamydia sp. - ovoid gram -ve - birds
Mycoplasma sp. - no gram stain (no wall) - young
Legionella sp. - bacilli gram -ve - travel/aircon.
7
Q
How is pneumonia severity graded?
A
CURB-65 C - confusion U - urea >7 R - RR >30 B - BP 65
8
Q
What curb65 scores indicate mild, mod and severe pneumonia. What treatment should be offered in the community for each?
A
0-1 = low - 5 days amoxicillin/macrolide 2 = mod - 7-10 days amoxicillin and macrolide 3-5 = severe- 7-10 days coamoxiclav and macrolide
9
Q
At what point should the treatment of a mild community pneumonia be extended?
A
No response after 3 days of treatment
10
Q
What investigations are vital in inpatient suspected pneumonia?
A
Fbc/u+e Blood culture if febrile CXR Atypical pneumonia screen if high curb ABG if SpO2
11
Q
What can be tested on atypical pneumonia screening?
A
Bloods, nose swab, throat swab, urine.
12
Q
What would suggest a patient with pneumonia was not ready for discharge?
A
More than 2 of: Pyrexia Rr >24 Pulse >100 SBP
13
Q
What should happen after a pneumonia patient has been discharged?
A
6 week chest xray
Depending on circumstance:
-hiv test
-immunoglobulins
14
Q
What pneumonic can be used in a persistent pneumonia to suggest why this may be the case?
A
Complications Host immunocompromised Antibiotics wrong Organism resistant Second diagnosis (PE, Ca, non detected organism)
15
Q
What are possible complications of pneumonia?
A
Abscess Empyema Pleurisy / effusion AF Sepsis
16
Q
Differentials of cxr consolidation
A
Pneumonia Tb Cancer Lobar collapse Haemorrhage
17
Q
Rough timescale for pneumonia recovery
A
1 week - fever resolved 4 weeks - chest pain and speutum reduced 6 weeks - cough and sob reduced 3 months - still fatigued 6 months - back to normal
18
Q
What is the definition of a pneumonia?
A
Infection of the lung parenchyma with cxr changes
19
Q
Risk factors for lung cancer?
A
Smoking Radiation Aspestos Arsenic Genetic
20
Q
4 main types of lung cancer?
A
Squamous cell carcinoma
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma
21
Q
Rarer types of lung cancer (not carcinomas).
A
Bronchial adenomas - mainly carcinoid
Mesotheliomas
22
Q
What lung cancers typically present with haemoptysis, recurrent infections and cough?
A
Proximal bronchial adenomas
23
Q
What are local effects caused by lung tumours?
A
Shortness of breath
Chest pain if pleura involved
Haemoptysis
Wheeze
24
Q
What are mass effects of lung cancers?
A
Weight loss
25
What are regional effects of lung cancers (effects distant from origin but directly caused)?
Pleural effusion
Swelling of face - SVC obstruction
Hoarseness of voice - recurrent laryngeal nerve compression
Dysponea - phrenic nerve compression
Dysphagia - oesophagel compression
Horners syndrome - sympathetic chain compression
26
What paraneoplastic effects of lung cancers can occur? Which are most associated with each?
Hypercalcaemia - PTHrP from squamous cell
SIADH - small cell carcinoma
Cushings - ACTH from small cell carcinoma
Anaemia
Clubbing
27
What are paraneoplastic syndroms
Signs and symptoms that are a consequence of cancer but not directly caused by the local presence of cancer cells/mass effect.
28
Where do lung cancers commonly metastasise too?
Liver
Bones
Brain
Adrenals
29
What is the histological appearence and immunohistochemistry of a squamous cell carcinoma?
Angulated prickly cells with p63 +ve
30
How do adenocarcinomas appear histologically?
Glandular
31
What term can be used to describe an area of white on a cxr?
Opacification
32
How would a pneumonectomy appear on a cxr after 2 days? After 10 days?
2 - opacification of the lower to middle zones with a straight line air gas interface
10 - total opacification
33
What lung lobes are in contact with what borders?
```
Rul - right mediasteinal
Rml - right heart boarder
Rll - right hemidiaphragm
Lul - left mediasteinum
Lingula - left heart boarder
Lll - left hemidiaphragm
```
34
How big should the heart be on a pa cxr?
35
What are cxr features of rul collapse?
Volume loss on right
Blurring of right upper mediasteinal border
Elevation of horizontal fissure
36
How would lung volume loss show on a cxr?
Elevation of hemidiaphragm
| Mediastinal shift towards effected side
37
You suspect lung cancer on a cxr. What imaging is the next choice?
Spiral CT chest
38
Which lobes of the right lung often collapse together? Why?
Rml and rll
| Obstruction of bronchus intermedius
39
How does a LLL collapse appear on a CXR?
Sail sign
Elevated left hemidiaphragm
Mediastinal shift to left
Compensatory overinflation of upper lobe causing increased translucency
40
What sign can be seen outside of the rib margins on cxr (not msk related)
Subcutanious ephysema
41
Causes of pneumomediastinum
Boerhaave syndrome
Iatrogenic during endoscopy
Asthma
42
What signs would help differentiate a right pneumonectomy from right total lung collapse?
Abrupt cut off of right bronchi
| Lack of surgical clips
43
How many anterior ribs should be visible on a cxr?
5-7
44
What is sarcoidosis?
A granulomatous inflammatory disorder
45
Presentation of sarcoidosis?
Asymptomatic
| SOB, dry cough, weight loss, night sweats, joint pains, fever
46
Cxr findings of sarcoidosis?
Bilateral hilar lymphadenopathy
| Progresses to bilateral reticulonodular opacities mainly in upper and middle lobes
47
What tests should be performed if sarcoidosis is supected of a CXR?
HRCT
Bronchoscopy with biopsy
Serum ace
48
Extraoulmonary manifestations of sarcoidosis?
Liver, eye, renal, skin
| Rarely cardiac, cns, gi
49
Pulmonary complications of sarcoidosis
Cor pulmonale to heart failure
50
What eye problem dose sarcoidosis cause? What is this?
Anterior uveitis
| Inflammation of the uvea including the iris and ciliary body
51
Hat skin problem does sarcoidosis cause?
Erythema nodosum
52
Prognosis of sarcoidosis? Possible treatments?
1-2/3rds resolve spontaniously in 2 years.
| If pulmonary infiltration treat with corticosteroids
53
When should iv antibiotics be used in pneumonia?
In severe pneumonia by curb65 and changed to oral once there has been a clinical improvement and patients temp has been normal for 24 hours
54
Differential diagnosis for a lung cavity on cxr?
Infections
Neoplasia
Granuloma
Trauma
55
If you think there is a pneumothorax on a cxr but arnt certain how could you make it more obvious on a repeat?
Perform it on expiration
56
How would bronchiectaisis appear on a cxr?
Hyperinflation
Bronchial wall thickening
Cystic spaces
57
Differentials for pulmonary nodules?
Infections granuloma
Bronchial adenoma
Primary or secondary malignancy
58
How does mesothelioma present on cxr?
Irregular pleural thickening as a peripheral shadowing
59
How does asbestosis appear on a cxr?
Irregular reticular opacities in the lung parenchyma
| Pleural plaques
60
Lung diseases caused by asbestos exposure?
```
Pleural effusions
Pleural plaques
Pleural thickening
Asbestosis
Mesothelioma
Bronchogenic carcinoma
```
61
How would you confirm a diagnosis of mesothelioma?
Ct guided biopsy
62
What are the t stages of tnm for lung cancer?
T0 - no evidence of primary
| T1 -
63
What are the n stages in tnm for lung cancer?
0 - none involved
1 - lymph node ipsolateral within the lung or hilum
2 - lymph node around carina or mediasteinum
3 - contralateral lymph node
64
What are the m stages of tnm for lung cancer?
0 - none
1a - other lung
1b - other organ
65
What are the different causes of opacification on CXR?
Consolidation - filled alveoli
Interstitial - involvement of supporting tissue
Nodule/mass - SOL
Atelectasis - collapse causing loss of air
Extra parenchymal
66
What is the appearance of and causes of consolidation on a CXR?
Ill defined opacity, loss of interfaces, air bronchograms, no volume loss
Pus - pneumonia
Water - LVF, ARDS, Liver failure, Renal failure
Blood - Trauma, vasculitis
Cells - sarcoid, carcinoma, organising pneumonia
67
How can consolidation be described in terms of distribution?
Lobar
Diffuse
Multifocal
68
Other than by distribution, how else may you want to classify consolidation on a CXR?
Acute vs chronic
69
Causes of a lobar consolidation?
```
Pneumonia
Neoplasm
Lymphoma
Haemorrhage
Sarcoidosis
```
70
Causes of multifocal consolidations on a cxr?
Disseminated bronchopneumonia inc TB
Vascular - wegeners
Neoplasia
Sarcoidosis
71
What are the different patterns of interstial opacity on a CXR?
Reticular
Cystic
Fine nodular
72
Causes of reticular interstital opacification on cxr?
Edema - heart failure
Interstital pnumonia
IPF
Amiodarone, methotrexate, nitofuritoin
73
Causes of nodular interstitial opacificationon cxr
Sarcoidosis
Metastasis
Tb
74
Causes of atelectasis
Mucus plugging
Foreign body
Tumour
75
Appearance of atelectasis on cxr
Sharply defined opacity
without air bronchograms
Volume loss
76
What is the size cut off between nodule and mass?
3cm
77
Causes of nodules on cxr?
```
Granuloma
Carcinoma
Metastasis
Abcess
Rheumatic nodule
Lymph node
```
78
Extra parenchymal causes of opacification on cxr?
Plural thickening or plaque
| Plural effusion
79
What is asthma?
A chronic inflammatory disease of the lungs
characterised by reversible airway obstruction
and increased airway responsiveness
80
Roughly what two major classifications can be applied to asthma?
Atopic vs non-atopic
| Eosinophilic vs non-eosinophilic
81
Why is it important to differentiate eosinophilic from non-eosinophilic asthma?
Eosinophilic is more steroid responsive, reacts poorly to steroid withdrawal and a high eosinophil count is associated with severity.
82
Other than asthma list causes for raised eosinophils.
```
Hayfever
COPD
SLE
Allergy
Drugs
Parasitic infection
Eosinophilic pneumonia
```
83
Features of mild acute asthma exacerbation
PEF >75% normal
84
Features of moderate acute asthma exacerbation
PEF 50-75% normal
85
Features of acute severe asthma exacerbation
PEF 33-50
Cannot complete sentences in one breath
Respiratory rate >25
Pulse >110
86
Features of life threatening acute asthma exacerbation
PEF
87
Features of near fatal acute asthma exacerbation
Raised pCO2
88
Management options for acute asthma?
```
Salbutamol
Ipratropium bromide
Steroids
Aminophylline
Referral to ITU
```
89
Criteria for asthma patient discharge
PEF >75
| Nebs stopped for 24 hours
90
Treatment requirements for discharge of asthma patient
Asthma nurse review
GP follow up
Resp clinic follow up
5 days oral prednisolone
91
What steroids can be used in the acute management of asthma?
40mg oral prednisolone or 100mg IV hypdrocortisone
92
Investigations required in life threatening asthma attack?
PEF
ABG
CXR
93
How does aminophyline work? Class?
Active ingredient theophylline
Phosphodiesterase 5 inhibitor increasing cAMP causing activating K channels allowing efflux and hyperpolarisation and decreased VOCC (thus decreased contraction) - results in bronchodilation
Methylxanthene
94
Effect of aminophylline on the heart? Mechanism?
Blocks adenosine receptors
| Causing tachycardia, arrhythmia, cardiac output
95
Non-cardiac side effects of aminophylline?
Convulsions
Nausea
Vomiting
Diarrheoa
96
What should be done on a patient on aminophylline?
Theophylline levels
97
What investigations can be used to diagnose asthma (long term)? What will be seen?
Serial peak flows - diurnal variation
Reversibility testing spirometry - obstructive pattern relieved by nebuliser
Blood and sputum eosinophils - raised
Methacholine challenge - give low dose nebulised methacholine - >20% reduction in FEV1 suggests obstruction
98
What cause should be considered in adults diagnosed with asthma?
Occupational asthma
99
Presentation of asthma?
Wheeze
Dry cough
Chest tightness
Worse at night / early morning
100
Chronic asthma treatment ladder
1 - SABA
2 - SABA + inhaled steroid 400mcg
3 - SABA + inhaled steroid 800mcg + LABA
4 - SABA + inhaled steroid 2000mcg + LABA + novel agent
5 - SABA + high dose inhaled steroid 2000mcg + LABA + novel agent + oral steroid
101
What novel agents can be considered in step four of asthma management?
Thophylline
| Montelukast
102
What should be considered when using stepwise asthma management?
Step up fast then step down
Use minimal step for relief
Consider compliance and technique before increasing step
103
What are the aims of long term asthma managment
```
Minimal symptoms
No exacerbations
Minimal use of reliever inhalor
Normal physical activity
Normal lung fuction testing
```
104
What are the issues with someone who overuses their reliever inhaler in asthma?
Indicates poor control
Increased side effects
Overuse can increase mast cell response worsening disese
105
Cellular mechanism of SABA in asthma?
Beta 2 stimulation - GalphaS release - increased AC activation - increased cAMP - increased K conductance - cell hyperpolarisation with muscle relaxation
106
Advantages of combining LABA with steroid in asthma?
Ease of use thus increased compliance
| Cant prescribe the LABA without the steroid
107
What is the SMART regime in asthma?
| Risk?
Use of symbicort (formoterol + budesonide) as a reliever inhaler
Slight increased infection risk
108
What is seretide?
Salmeterol/fluticasone
109
What is fostair
Formetarol + beclomethasone
110
Fast acting LABA for asthma?
Formotarol
111
How could a steroid be altered to reduce side effects in asthma? How?
Add lipophilic side chain
Stonger binding in lungs
Increased uptake locally
Faster hepatic metabolism
112
What steroids for asthma have high first pass metabolism thus have lower side effects if swallowed?
Fluticasone
| Budesonide
113
Which steroid inhaled in asthma has low first pass metabolism so high bioavaliablity if swallowed?
Beclamethasone
114
Pathology of asthma?
Epithelial damage with airway remodelling - hyperresponsivness
Inflammation with high eosinophils and mast cells - mucosal oedema
Increased mucous glands - mucous pougging
115
Asthma triggers?
```
Smoking
Urti
Exercise
Cold air
Allergens
Pollution
Occupational irritants
Drugs
Stress
```
116
What is copd?
A progressive disease causing airflow obstruction that is not fully reversible and does not change markedly over several months.
Usually caused by smoking.
117
Diagnostic definition of chronic bronchitis?
Sputum production most days for 3 months of 2 sucessive years
118
Diagnostic criteria of emphysema?
Histological changes with enlarged air spaces distal to terminal bronchioles with alveolar wall destruction
119
Causes of COPD
Smoking
Alpha 1 antitrypsin deficiency
Industrial exposure
120
Long term COPD mangement that alters prognosis
Stop smoking
Lung volume reduction
Long term oxygen therapy
Vaccinations
121
Indications for long term oxygen therapy in COPD
Persistant pO2
122
Contraindications for long term oxygen therapy in COPD
Smoker
| Co2 retainer
123
Symptom relief in COPD
```
Mucolytics
Steroids
Bronchodilators
Pulmonary rehab
Oromorph
```
124
What is the role of oromorph in COPD
Antianxiety
125
What is the role of pulmonary rehab in copd?
Break the cycle of breathlessness and exercise avoidance
126
Emergency treatment of a COPD exacerbation not in resp failure?
Steroids
Antibiotics
Maintain SpO2
Aminophyline
127
Emergency treatment of COPD in resp failure?
BIPAP
| ITU
128
Indications exacerbation of COPD is infective?
Change in speutum volume and or colour
Fever
Raised WCC +/- CRP
129
What steroid should be used in exacerbation of COPD? For how long?
Prednisolone 30mg for a week
130
A patient has a low pH with a high co2 and a high bicarbonate - what sort of acid base disturbance do they have?
A partially compensated respiratory acidosis
131
A patient has a low pH with a low co2 and a low bicarbonate - what sort of acid base disturbance do they have?
A partially compensated metabolic acidosis
132
A patient has a high pH with a high co2 and a high bicarbonate - what sort of acid base disturbance do they have?
A partially compensated metabolic alkalosis
133
A patient has a high pH with a low co2 and a low bicarbonate - what sort of acid base disturbance do they have?
A partially compensated respiratory alkalosis
134
What is the anion gap?
| What is its relevance in ABG interpretation?
The difference between primary cations (Na, K) and anions (Cl, HCO3) in serum. As there are slightly more unmeasured anions there is a gap of 10-15mmol/l
It is used to assess cause of metabolic acidosis.
135
Interpret a metabolic acidosis on an abg with a high anion gap
If anion gap is raised bicarbonate has been replaced with something other than chlorine - e.g. Lactic acidosis, poisoning, dka
136
Interpret a metabolic acidosis on an abg with a normal anion gap
Bicarbonate has been replaced with chlorine usually due to diarrhoea but also renal loss (tubular acidosis).
137
What can be used to determine whether a hypoxaemia seen on an ABG is due to hypoventilation or poor diffusion?
Roughly how does it work?
The A-a gradient
PAO2(alveolar oxygen) - PaO2 (arterial oxygen) should be less than 2kPa (4 in the elderly) meaning the oxygen nearly reaches equilibrium over the alveolar membrane. If hypoxic and Aa gradient normal then ventilation is decreased (e.g. Opiate od, congenital chest wall defect). If hypoxic and Aa gradient is raised then there is a problem with oxygen diffusion (e.g. Fibrosis, shunting)
138
How is alveolar oxygen calculated when working out the Aa gradient?
PIO2 - (PaCO2/0.8)
Pressure of inspired oxygen (air pressure minus water vapour times fraction of inspired oxygen) minus partial pressure of carbon dioxide (equal to the arterial pressure/0.8)
139
Causes of type one respiratory failure (groups and examples)
```
VQ mismatch:
Some poorly perfused alveoli - PE
Some poorly ventilated alveoli - pneumonia, early acute asthma
Lengthened diffusion pathway
Pulmonary oedema
Pulmonary fibrosis
```
140
Causes of type two respiratory failure (groups and examples
Ineffective ventilation:
Poor respiratory effort - narcotics, muscle weakness
Chest wall disease - kyphosis, trauma
Hard to ventilate lungs - COPD, asthma
141
What sort of respiratory failure does copd cause?
Initially type one as vq mismatch
| Progresses to type two as resistance effected
142
Causes of haemoptysis
```
Infection
Cancer
PE
Coagulopathy
Vasculitis
```
143
Systemic symptoms of pulmonary TB
Weight loss
Night sweats
Fever
Malaise
144
Symptoms of respiratory tb
Cough with purulent sputum
Haemoptysis
Pleural effusion (sob, pleuritic chest pain)
145
Symptoms of non-respiratory tb
```
Erythema nodosum
Lymphadenopathy
Meningitis
Pericardial effusion
Kidney disease
```
146
Initial management of suspected respiratory tb in hospital inc diagnostics
```
ABCDE approach
Isolation to side room
3x sputum samples for culture - if unable to provide - bronchoscopy
Bloods - FBC, CRP, HIV
Consider CT
```
147
Management of confirmed pulmonary TB in hospital
Supportive care
Maintain isolation
Notify pubic health department
Antibiotic therapy
148
Antibiotics for TB
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
149
Baseline tests before starting tb treatment? What should be considered?
Lfts
Visual acuity
Vit d
No ethambutol if in coma
150
What test can be used for TB in a patient who has been vaccinated? What sort of test is it? What can they not do?
Quantiferron gold
Interferon gamma release assay
Distinguish between latent and active tb
151
General signs and symptoms of interstitial lung disease?
SOB, Dry cough, weight loss
| Diffuse or basal creps, cor-pulmonale, clubbing
152
CXR signs of intersitital lung disease?
Reticular shadowing
153
Signs of interstitial lung disease on CT
Honeycombing
Ground glass
Traction bronchiectasis
154
What does a ground glass apperence on ct suggest ininterstitial lung disease?
Steroid responsiveness
155
How is sarcoidosis usually detected?
Routine cxr
156
What are the histological features of sarcoidosis?
Epitheloid, macrophage and tcell granulomas
157
Blood test findings in sarcoidosis?
Lyphopneoa due to lung sequestration
Raised ACE
Normochromic normocytic anaemia
158
What is the prognosis of sarcoidosis with pulmonary infiltration vs sarcoidosis without?
Increased risk of progression to cor-pulmonale
159
Extrapulmonary manifestations of sarcoidosis?
```
Erythema nodosum
Anterior uveitis
Arthritis
Calcium derangement
Neurological
Hepatosplenomegally
Arrhythmia
```
160
Diagnosis for sarcoidosis?
Transbronchial biopsy
161
Treatment options for sarcoidosis?
Conservative! 2/3rds resolve spontaniously in two years. Corticosteroids if pulmonary infiltration that is not resolving.
162
Which sort of sarcoidosis has the worst prognosis?
Infiltrative without bihilar lymphadenopathy!
163
Other than sarcoidosis give another group of diseases that cause granulomatous interstitial lung disease
2 examples
Vasculitis
Granulomatosis with polyangitis
Churg strauss syndrome
164
What would tend to be raised in an interstitial lung disease caused by granulomatosis with vasculitits?
ANCA
165
What is an almost pathamonomic sign on CXR or granulomatosis with polyangitis? How do lesions appear?
Lesions move with time
| Single or multinodular masses and cavitation
166
What is the commonest cause of intersitial lung disease?
Idiopathic pulmonary fibrosis
167
What is the pathological mechanism in idiopathic pulmonary fibrosis?
Uncertain
| Inflammation causing activation of fibroblasts and thus collogen deposition
168
Where in the lungs does idiopathic pulmonary fibrosis usually effect? CXR changes?
Bases
| Ground glass appearence
169
What spirometery change would be expected in idiopathic pulmonary fibrosis?
Restrictive pattern
170
What would an ABG look like in severe idiopathic pulmonary fibrosis?
Type 1 resp failure (low o2) with hypocapnia (due to hyperventilation)
171
What blood tests may be raised in idiopathic pulmonary fibrosis?
ANCA and RF
172
Prognosis of idiopathic pulmonary fibrosis?
Mean survival 5 years
173
Types of pneumothorax?
Spontanious primary - pristine lung
Spontanious secondary - underlying lung disease or >50 and smoker
Traumatic
Iatrogenic
174
Complications (with signs) of a pneumothorax?
Tension pneumothorax - cardiac compromise
| Pneumomediastinum - subcutanious emphysema and precodial crunching
175
What is precordial crunching in a pneumothorax called?
Hammans sign
176
Treatment options for a primary pneumothorax
2cm or breathless - aspirate and review in two weeks
| If unsuccessful retry or drain
177
Treatment options for a secondary pneumothroax
2cm, failed aspiration or breathless - drain
178
Post discharge advice for pneumothorax?
No flying for 6 weeks
| No diving ever
179
Causes of brochiectasis?
Ciliary clearance - CF, primary ciliary dyskinesia
Autoimmune - RA, UC
Obstruction
Infection - pneumonia, tb, measles, pertussis
Immunodeficiency - primary, HIV
180
Common infections in patients with bronchiectaisis
```
Hamophilius influenza
Pseudomonas aeruginsoa
Moraxella cararrhalis
Aspergillus
Candidia
```
181
Symptoms of bronchiectasis?
Cough
Purulent sputum
Haemoptysis
182
Signs of bronchiectasis
Clubbing
Crepitations
Wheeze
183
What sort of ct should be used to look at suspected bronchiectasis? What may it show?
HRCT
| Signet ring sign (thick and dilated bronchi with smaller vessels)
184
Treatment options for bronchiectasis
Physiotherapy
Treatment and prophylactic antibiotics
Treat underlying condition
Consideration to bronchodilators and steroids
185
How would an obstructive deficit appear on volume time spirometry and flow volume loop?
Low fev1 vs fvc
| Scooped out appearance
186
How does a restrictive deficit tend to appear on volume time spirometry and flow volume loop?
Low fvc and fev1 with preserved ratio
| Narrowed appearance
187
What fev1:fvc ratios represent mild, mod and severe pulmonary obstruction?
Mild 65-80%
Mod 50-65%
Severe
188
What may drop prior to fev1:fvc in very mild obstructive disease? What is it?
Fef 25-75%
| Average forced expiratory flow in the mid portion of fvc
189
How do fixed, variable extrathoracic and variable intrathoracic obstructions appear on flow volume loops?
Fixed - flattening of insp and exp portion
Extrathoracic - flattening of insp portion
Intrathoracic - flattening of exp portion
190
Examples of fixed airway obstructions?
Tumours
| Tracheal stenosis
191
Examples of variable extrathroacic airway obstructions?
Vocal cord dyskinesia
192
Examples of variable interthoracic airway obstructions
Bronchiectaisis
193
What is type 1 hypersensitivity?
Antigenic cross linking of IgE on mast cells triggering histamine release e.g. Anaphylaxis
194
What is type 2 hypersensitivity?
Antigen binds to host protein forming hapten on host cell
IgM and IgG binding leading to immune destruction of cell
E.g. Haemolytic anaemia, agranulocytosis, thrombocytopenia
195
What is type 3 hypersensitivity?
IgG antibody antigen complex deposited in vessel wall with continued complement activation
E.g. Serum sickness, arthritis, glomerulonephritis
196
What is type 4 hypersensitivity?
Th1 helper t cells activated by apc
Activation of macrophages
Inflammation
E.g. Contact dermatitis
197
What testing can be done to look for type 1 hypersensitivity?
Skin prick testing (standardised solutions)
Pin prick testing (sample scraped onto a lancet - wide range but risk of large dose)
IgE assay ELISA (expensive but no risk of harm)
Challenge test (high risk of harm)
198
Treatment of massive haemoptysis?
```
Lie patient on side of suspected lesion
Tranexamic acid
Stop anticoagulation
Consider vit K
CT aortogram +/- embolisation
```
199
Signs of massive PE
| Management?
Hypotension/imminent cardiac arrest
Signs of right heart strain on ct/echo
Consider thrombolysis with altoplase
200
Presentations of CF?
Meconium ileus - bowel blocked in newborns by secretions
Intestinal malabsorption - pancreatic insufficiency
Recurrent chest infections - bronchiectasis
Opportunistic newborn screening
201
Lifestyle advice for CF patients?
```
No smoking
Avoid other CF
Avoid people with infections
Avoid jacuzzis
Avoid stables/compost (aspergillus)
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202
Three most common causes of massive haemoptysis
Tb
Bronchiectasis
Lung abcess
203
What is the ONLY indication for urgent (pre diagnosis) chest drain in a pleural effusion? How would it be recognised on aspiration?
Empyema
| pH of pleural fluid
204
What are causes of transudate pleural effusions?
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Heart failure
Cirrhosis
Hypoalbuminia (nephrotic syndrome)
Hypothyroidism
PE
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205
What are causes of exudative pleural effusions?
Malignancy
Infections
Inflammation (RA, pancreatitis)
Lymphatic disorders
206
What defines whether a pleural effusion is transudative or exudative?
Pleural proteins 30g/L
207
What is the WHO performance scale?
0 - normal
1 - restricted strenuous but can do light work
2 - self caring and out of bed or chair >50% of day but off work
3 - limited self care, in bed or chair > 50% of day
4 - cannot self care, confined to bed or chair
5 - dead
208
What is the MRC dysponea scale?
1 - not troubled by sob except on strenuous exercise
2 - sob when hurrying or slight hill
3 - has to stop for breath or slower than contemporaries
4 - stops for breath after 100m or 2 minutes
5 - too breathless to leave the house, breathless on dressing or undressing
209
Causes of OSA
Small pharyngeal opening (which narrows a normal amount)- fat, large tonsils, bone abnormalities
Excessive narrowing at night (on a normal sized opening during the day) - obesity, neuromuscular disease, muscle relaxants (inc. alcohol), age
210
Issues with OSA
Sleep fragmentation
Disturbance of partners sleep!
Excessive daytime sleepiness
Hypertension
211
What is used to assess daytime sleepiness in osa? What diagnostic tests are available?
Epworth sleepiness scale
Overnight pulse oximetry
Limited sleep study - movements, snoring, heart rate
Full sleep study - as above with EEG
212
Management of OSA
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Weight loss
Sleeping position
Decrease alcohol
Mandibular advancement devices
Nasal CPAP
Pharyngeal surgery
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213
Treatments of atelectasis
Cause dependant
Pulmonary physiotherapy - breathing and percussion
Mucus thinners
Broncoscopic opening
214
What are the two main modes of niv? When are they useful?
CPAP - useful in T1RF - pneumonia, CHF and OSA, splints airways and drives out fluid
BIPAP - useful in T2RF - COPD, splints alveoli and provides respiratory support
215
Why do copd and asthma cause difficulty in expiration?
In inspiration airways dilated thus highest resistance trachea.
In forced expiration small airways compressed as they lack cartilage. As they are now the area of highest resistance air becomes trapped in alveoli.
216
Contraindications to niv?
Gcs
217
Why does diarrhoea cause a normal anion gap acidosis?
Diarrhoea causes loss of bicarb and loss of na but not much loss of cl. Thus bicarb drops and cl relatively increases in respect to na.
218
Causes of normal anion gap acidosis
Diarrhoea
Overenthusiastic na cl fluid therapy
Renal tubular acidosis
219
Causes of metabolic alkalosis
Vomiting
Diuretics
Iatrogenic
220
Treatment of hospital aquired pneumonia?
Piperacillin + gentamycin
221
Types of aspergillus lung disease with brief description
Asthma - T1 hypersensitivity
Allergic bronchopulmonary aspegillosis - T1 +T3 hypersensitivity from wheezing to bronchiectasis
Aspergillioma - fungus ball within pre existing cavity - cough, large haemoptysis, weight loss
Invasive aspergillosis - immunocompramised
Extrinsic allergic alveolitis - interstitial lung disease
