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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

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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)

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3
Q

When dose staphylococcus aureus usually cause pneumonia?

A

In patient with viral chest infection.

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4
Q

What viruses may cause pneumonia?

A

Influenza
Parainfluenza
Respiratory syncytial virus

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5
Q

What opportunistic infections cause pneumonia?

A 
HSV
CMV
Candidia
Aspergillus
Pneumocystis jirovecii
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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.

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7
Q

How is pneumonia severity graded?

A 
CURB-65
C - confusion
U - urea >7
R - RR >30
B - BP 65
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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
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9
Q

At what point should the treatment of a mild community pneumonia be extended?

A

No response after 3 days of treatment

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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
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11
Q

What can be tested on atypical pneumonia screening?

A

Bloods, nose swab, throat swab, urine.

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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
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13
Q

What should happen after a pneumonia patient has been discharged?

A

6 week chest xray
Depending on circumstance:
-hiv test
-immunoglobulins

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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)
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15
Q

What are possible complications of pneumonia?

A 
Abscess
Empyema 
Pleurisy / effusion
AF
Sepsis
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16
Q

Differentials of cxr consolidation

A 
Pneumonia
Tb
Cancer
Lobar collapse
Haemorrhage
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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
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18
Q

What is the definition of a pneumonia?

A

Infection of the lung parenchyma with cxr changes

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19
Q

Risk factors for lung cancer?

A 
Smoking
Radiation
Aspestos
Arsenic 
Genetic
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20
Q

4 main types of lung cancer?

A

Squamous cell carcinoma
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma

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21
Q

Rarer types of lung cancer (not carcinomas).

A

Bronchial adenomas - mainly carcinoid

Mesotheliomas

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22
Q

What lung cancers typically present with haemoptysis, recurrent infections and cough?

A

Proximal bronchial adenomas

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23
Q

What are local effects caused by lung tumours?

A

Shortness of breath
Chest pain if pleura involved
Haemoptysis
Wheeze

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24
Q

What are mass effects of lung cancers?

A

Weight loss

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25
Q

What are regional effects of lung cancers (effects distant from origin but directly caused)?

A

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

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26
Q

What paraneoplastic effects of lung cancers can occur? Which are most associated with each?

A

Hypercalcaemia - PTHrP from squamous cell
SIADH - small cell carcinoma
Cushings - ACTH from small cell carcinoma
Anaemia
Clubbing

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27
Q

What are paraneoplastic syndroms

A

Signs and symptoms that are a consequence of cancer but not directly caused by the local presence of cancer cells/mass effect.

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28
Q

Where do lung cancers commonly metastasise too?

A

Liver
Bones
Brain
Adrenals

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29
Q

What is the histological appearence and immunohistochemistry of a squamous cell carcinoma?

A

Angulated prickly cells with p63 +ve

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30
Q

How do adenocarcinomas appear histologically?

A

Glandular

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31
Q

What term can be used to describe an area of white on a cxr?

A

Opacification

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32
Q

How would a pneumonectomy appear on a cxr after 2 days? After 10 days?

A

2 - opacification of the lower to middle zones with a straight line air gas interface
10 - total opacification

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33
Q

What lung lobes are in contact with what borders?

A 
Rul - right mediasteinal
Rml - right heart boarder
Rll - right hemidiaphragm
Lul - left mediasteinum
Lingula - left heart boarder
Lll - left hemidiaphragm
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34
Q

How big should the heart be on a pa cxr?

A
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35
Q

What are cxr features of rul collapse?

A

Volume loss on right
Blurring of right upper mediasteinal border
Elevation of horizontal fissure

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36
Q

How would lung volume loss show on a cxr?

A

Elevation of hemidiaphragm

Mediastinal shift towards effected side

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37
Q

You suspect lung cancer on a cxr. What imaging is the next choice?

A

Spiral CT chest

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38
Q

Which lobes of the right lung often collapse together? Why?

A

Rml and rll

Obstruction of bronchus intermedius

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39
Q

How does a LLL collapse appear on a CXR?

A

Sail sign
Elevated left hemidiaphragm
Mediastinal shift to left
Compensatory overinflation of upper lobe causing increased translucency

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40
Q

What sign can be seen outside of the rib margins on cxr (not msk related)

A

Subcutanious ephysema

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41
Q

Causes of pneumomediastinum

A

Boerhaave syndrome
Iatrogenic during endoscopy
Asthma

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42
Q

What signs would help differentiate a right pneumonectomy from right total lung collapse?

A

Abrupt cut off of right bronchi

Lack of surgical clips

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43
Q

How many anterior ribs should be visible on a cxr?

A

5-7

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44
Q

What is sarcoidosis?

A

A granulomatous inflammatory disorder

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45
Q

Presentation of sarcoidosis?

A

Asymptomatic

SOB, dry cough, weight loss, night sweats, joint pains, fever

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46
Q

Cxr findings of sarcoidosis?

A

Bilateral hilar lymphadenopathy

Progresses to bilateral reticulonodular opacities mainly in upper and middle lobes

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47
Q

What tests should be performed if sarcoidosis is supected of a CXR?

A

HRCT
Bronchoscopy with biopsy
Serum ace

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48
Q

Extraoulmonary manifestations of sarcoidosis?

A

Liver, eye, renal, skin

Rarely cardiac, cns, gi

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49
Q

Pulmonary complications of sarcoidosis

A

Cor pulmonale to heart failure

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50
Q

What eye problem dose sarcoidosis cause? What is this?

A

Anterior uveitis

Inflammation of the uvea including the iris and ciliary body

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51
Q

Hat skin problem does sarcoidosis cause?

A

Erythema nodosum

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52
Q

Prognosis of sarcoidosis? Possible treatments?

A

1-2/3rds resolve spontaniously in 2 years.

If pulmonary infiltration treat with corticosteroids

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53
Q

When should iv antibiotics be used in pneumonia?

A

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

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54
Q

Differential diagnosis for a lung cavity on cxr?

A

Infections
Neoplasia
Granuloma
Trauma

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55
Q

If you think there is a pneumothorax on a cxr but arnt certain how could you make it more obvious on a repeat?

A

Perform it on expiration

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56
Q

How would bronchiectaisis appear on a cxr?

A

Hyperinflation
Bronchial wall thickening
Cystic spaces

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57
Q

Differentials for pulmonary nodules?

A

Infections granuloma
Bronchial adenoma
Primary or secondary malignancy

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58
Q

How does mesothelioma present on cxr?

A

Irregular pleural thickening as a peripheral shadowing

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59
Q

How does asbestosis appear on a cxr?

A

Irregular reticular opacities in the lung parenchyma

Pleural plaques

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60
Q

Lung diseases caused by asbestos exposure?

A 
Pleural effusions
Pleural plaques
Pleural thickening
Asbestosis 
Mesothelioma
Bronchogenic carcinoma
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61
Q

How would you confirm a diagnosis of mesothelioma?

A

Ct guided biopsy

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62
Q

What are the t stages of tnm for lung cancer?

A

T0 - no evidence of primary

T1 -

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63
Q

What are the n stages in tnm for lung cancer?

A

0 - none involved
1 - lymph node ipsolateral within the lung or hilum
2 - lymph node around carina or mediasteinum
3 - contralateral lymph node

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64
Q

What are the m stages of tnm for lung cancer?

A

0 - none
1a - other lung
1b - other organ

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65
Q

What are the different causes of opacification on CXR?

A

Consolidation - filled alveoli
Interstitial - involvement of supporting tissue
Nodule/mass - SOL
Atelectasis - collapse causing loss of air
Extra parenchymal

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66
Q

What is the appearance of and causes of consolidation on a CXR?

A

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

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67
Q

How can consolidation be described in terms of distribution?

A

Lobar
Diffuse
Multifocal

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68
Q

Other than by distribution, how else may you want to classify consolidation on a CXR?

A

Acute vs chronic

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69
Q

Causes of a lobar consolidation?

A 
Pneumonia
Neoplasm
Lymphoma
Haemorrhage 
Sarcoidosis
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70
Q

Causes of multifocal consolidations on a cxr?

A

Disseminated bronchopneumonia inc TB
Vascular - wegeners
Neoplasia
Sarcoidosis

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71
Q

What are the different patterns of interstial opacity on a CXR?

A

Reticular
Cystic
Fine nodular

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72
Q

Causes of reticular interstital opacification on cxr?

A

Edema - heart failure
Interstital pnumonia
IPF
Amiodarone, methotrexate, nitofuritoin

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73
Q

Causes of nodular interstitial opacificationon cxr

A

Sarcoidosis
Metastasis
Tb

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74
Q

Causes of atelectasis

A

Mucus plugging
Foreign body
Tumour

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75
Q

Appearance of atelectasis on cxr

A

Sharply defined opacity
without air bronchograms
Volume loss

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76
Q

What is the size cut off between nodule and mass?

A

3cm

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77
Q

Causes of nodules on cxr?

A 
Granuloma
Carcinoma
Metastasis
Abcess
Rheumatic nodule
Lymph node
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78
Q

Extra parenchymal causes of opacification on cxr?

A

Plural thickening or plaque

Plural effusion

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79
Q

What is asthma?

A

A chronic inflammatory disease of the lungs
characterised by reversible airway obstruction
and increased airway responsiveness

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80
Q

Roughly what two major classifications can be applied to asthma?

A

Atopic vs non-atopic

Eosinophilic vs non-eosinophilic

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81
Q

Why is it important to differentiate eosinophilic from non-eosinophilic asthma?

A

Eosinophilic is more steroid responsive, reacts poorly to steroid withdrawal and a high eosinophil count is associated with severity.

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82
Q

Other than asthma list causes for raised eosinophils.

A 
Hayfever
COPD
SLE
Allergy 
Drugs
Parasitic infection
Eosinophilic pneumonia
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83
Q

Features of mild acute asthma exacerbation

A

PEF >75% normal

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84
Q

Features of moderate acute asthma exacerbation

A

PEF 50-75% normal

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85
Q

Features of acute severe asthma exacerbation

A

PEF 33-50
Cannot complete sentences in one breath
Respiratory rate >25
Pulse >110

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86
Q

Features of life threatening acute asthma exacerbation

A

PEF

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87
Q

Features of near fatal acute asthma exacerbation

A

Raised pCO2

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88
Q

Management options for acute asthma?

A 
Salbutamol 
Ipratropium bromide
Steroids
Aminophylline
Referral to ITU
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89
Q

Criteria for asthma patient discharge

A

PEF >75

Nebs stopped for 24 hours

90
Q

Treatment requirements for discharge of asthma patient

A

Asthma nurse review
GP follow up
Resp clinic follow up
5 days oral prednisolone

91
Q

What steroids can be used in the acute management of asthma?

A

40mg oral prednisolone or 100mg IV hypdrocortisone

92
Q

Investigations required in life threatening asthma attack?

A

PEF
ABG
CXR

93
Q

How does aminophyline work? Class?

A

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
Q

Effect of aminophylline on the heart? Mechanism?

A

Blocks adenosine receptors

Causing tachycardia, arrhythmia, cardiac output

95
Q

Non-cardiac side effects of aminophylline?

A

Convulsions
Nausea
Vomiting
Diarrheoa

96
Q

What should be done on a patient on aminophylline?

A

Theophylline levels

97
Q

What investigations can be used to diagnose asthma (long term)? What will be seen?

A

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
Q

What cause should be considered in adults diagnosed with asthma?

A

Occupational asthma

99
Q

Presentation of asthma?

A

Wheeze
Dry cough
Chest tightness
Worse at night / early morning

100
Q

Chronic asthma treatment ladder

A

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
Q

What novel agents can be considered in step four of asthma management?

A

Thophylline

Montelukast

102
Q

What should be considered when using stepwise asthma management?

A

Step up fast then step down
Use minimal step for relief
Consider compliance and technique before increasing step

103
Q

What are the aims of long term asthma managment

A 
Minimal symptoms
No exacerbations
Minimal use of reliever inhalor 
Normal physical activity 
Normal lung fuction testing
104
Q

What are the issues with someone who overuses their reliever inhaler in asthma?

A

Indicates poor control
Increased side effects
Overuse can increase mast cell response worsening disese

105
Q

Cellular mechanism of SABA in asthma?

A

Beta 2 stimulation - GalphaS release - increased AC activation - increased cAMP - increased K conductance - cell hyperpolarisation with muscle relaxation

106
Q

Advantages of combining LABA with steroid in asthma?

A

Ease of use thus increased compliance

Cant prescribe the LABA without the steroid

107
Q

What is the SMART regime in asthma?

Risk?

A

Use of symbicort (formoterol + budesonide) as a reliever inhaler
Slight increased infection risk

108
Q

What is seretide?

A

Salmeterol/fluticasone

109
Q

What is fostair

A

Formetarol + beclomethasone

110
Q

Fast acting LABA for asthma?

A

Formotarol

111
Q

How could a steroid be altered to reduce side effects in asthma? How?

A

Add lipophilic side chain
Stonger binding in lungs
Increased uptake locally
Faster hepatic metabolism

112
Q

What steroids for asthma have high first pass metabolism thus have lower side effects if swallowed?

A

Fluticasone

Budesonide

113
Q

Which steroid inhaled in asthma has low first pass metabolism so high bioavaliablity if swallowed?

A

Beclamethasone

114
Q

Pathology of asthma?

A

Epithelial damage with airway remodelling - hyperresponsivness
Inflammation with high eosinophils and mast cells - mucosal oedema
Increased mucous glands - mucous pougging

115
Q

Asthma triggers?

A 
Smoking 
Urti
Exercise
Cold air
Allergens
Pollution
Occupational irritants 
Drugs
Stress
116
Q

What is copd?

A

A progressive disease causing airflow obstruction that is not fully reversible and does not change markedly over several months.
Usually caused by smoking.

117
Q

Diagnostic definition of chronic bronchitis?

A

Sputum production most days for 3 months of 2 sucessive years

118
Q

Diagnostic criteria of emphysema?

A

Histological changes with enlarged air spaces distal to terminal bronchioles with alveolar wall destruction

119
Q

Causes of COPD

A

Smoking
Alpha 1 antitrypsin deficiency
Industrial exposure

120
Q

Long term COPD mangement that alters prognosis

A

Stop smoking
Lung volume reduction
Long term oxygen therapy
Vaccinations

121
Q

Indications for long term oxygen therapy in COPD

A

Persistant pO2

122
Q

Contraindications for long term oxygen therapy in COPD

A

Smoker

Co2 retainer

123
Q

Symptom relief in COPD

A 
Mucolytics
Steroids
Bronchodilators
Pulmonary rehab
Oromorph
124
Q

What is the role of oromorph in COPD

A

Antianxiety

125
Q

What is the role of pulmonary rehab in copd?

A

Break the cycle of breathlessness and exercise avoidance

126
Q

Emergency treatment of a COPD exacerbation not in resp failure?

A

Steroids
Antibiotics
Maintain SpO2
Aminophyline

127
Q

Emergency treatment of COPD in resp failure?

128
Q

Indications exacerbation of COPD is infective?

A

Change in speutum volume and or colour
Fever
Raised WCC +/- CRP

129
Q

What steroid should be used in exacerbation of COPD? For how long?

A

Prednisolone 30mg for a week

130
Q

A patient has a low pH with a high co2 and a high bicarbonate - what sort of acid base disturbance do they have?

A

A partially compensated respiratory acidosis

131
Q

A patient has a low pH with a low co2 and a low bicarbonate - what sort of acid base disturbance do they have?

A

A partially compensated metabolic acidosis

132
Q

A patient has a high pH with a high co2 and a high bicarbonate - what sort of acid base disturbance do they have?

A

A partially compensated metabolic alkalosis

133
Q

A patient has a high pH with a low co2 and a low bicarbonate - what sort of acid base disturbance do they have?

A

A partially compensated respiratory alkalosis

134
Q

What is the anion gap?

What is its relevance in ABG interpretation?

A

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
Q

Interpret a metabolic acidosis on an abg with a high anion gap

A

If anion gap is raised bicarbonate has been replaced with something other than chlorine - e.g. Lactic acidosis, poisoning, dka

136
Q

Interpret a metabolic acidosis on an abg with a normal anion gap

A

Bicarbonate has been replaced with chlorine usually due to diarrhoea but also renal loss (tubular acidosis).

137
Q

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?

A

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
Q

How is alveolar oxygen calculated when working out the Aa gradient?

A

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
Q

Causes of type one respiratory failure (groups and examples)

A 
VQ mismatch:
Some poorly perfused alveoli - PE
Some poorly ventilated alveoli - pneumonia, early acute asthma 
Lengthened diffusion pathway 
Pulmonary oedema
Pulmonary fibrosis
140
Q

Causes of type two respiratory failure (groups and examples

A

Ineffective ventilation:
Poor respiratory effort - narcotics, muscle weakness
Chest wall disease - kyphosis, trauma
Hard to ventilate lungs - COPD, asthma

141
Q

What sort of respiratory failure does copd cause?

A

Initially type one as vq mismatch

Progresses to type two as resistance effected

142
Q

Causes of haemoptysis

A 
Infection 
Cancer
PE
Coagulopathy 
Vasculitis
143
Q

Systemic symptoms of pulmonary TB

A

Weight loss
Night sweats
Fever
Malaise

144
Q

Symptoms of respiratory tb

A

Cough with purulent sputum
Haemoptysis
Pleural effusion (sob, pleuritic chest pain)

145
Q

Symptoms of non-respiratory tb

A 
Erythema nodosum
Lymphadenopathy 
Meningitis 
Pericardial effusion
Kidney disease
146
Q

Initial management of suspected respiratory tb in hospital inc diagnostics

A 
ABCDE approach
Isolation to side room 
3x sputum samples for culture - if unable to provide - bronchoscopy
Bloods - FBC, CRP, HIV
Consider CT
147
Q

Management of confirmed pulmonary TB in hospital

A

Supportive care
Maintain isolation
Notify pubic health department
Antibiotic therapy

148
Q

Antibiotics for TB

A

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

149
Q

Baseline tests before starting tb treatment? What should be considered?

A

Lfts
Visual acuity
Vit d
No ethambutol if in coma

150
Q

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?

A

Quantiferron gold
Interferon gamma release assay
Distinguish between latent and active tb

151
Q

General signs and symptoms of interstitial lung disease?

A

SOB, Dry cough, weight loss

Diffuse or basal creps, cor-pulmonale, clubbing

152
Q

CXR signs of intersitital lung disease?

A

Reticular shadowing

153
Q

Signs of interstitial lung disease on CT

A

Honeycombing
Ground glass
Traction bronchiectasis

154
Q

What does a ground glass apperence on ct suggest ininterstitial lung disease?

A

Steroid responsiveness

155
Q

How is sarcoidosis usually detected?

A

Routine cxr

156
Q

What are the histological features of sarcoidosis?

A

Epitheloid, macrophage and tcell granulomas

157
Q

Blood test findings in sarcoidosis?

A

Lyphopneoa due to lung sequestration
Raised ACE
Normochromic normocytic anaemia

158
Q

What is the prognosis of sarcoidosis with pulmonary infiltration vs sarcoidosis without?

A

Increased risk of progression to cor-pulmonale

159
Q

Extrapulmonary manifestations of sarcoidosis?

A 
Erythema nodosum 
Anterior uveitis 
Arthritis 
Calcium derangement 
Neurological 
Hepatosplenomegally 
Arrhythmia
160
Q

Diagnosis for sarcoidosis?

A

Transbronchial biopsy

161
Q

Treatment options for sarcoidosis?

A

Conservative! 2/3rds resolve spontaniously in two years. Corticosteroids if pulmonary infiltration that is not resolving.

162
Q

Which sort of sarcoidosis has the worst prognosis?

A

Infiltrative without bihilar lymphadenopathy!

163
Q

Other than sarcoidosis give another group of diseases that cause granulomatous interstitial lung disease
2 examples

A

Vasculitis
Granulomatosis with polyangitis
Churg strauss syndrome

164
Q

What would tend to be raised in an interstitial lung disease caused by granulomatosis with vasculitits?

165
Q

What is an almost pathamonomic sign on CXR or granulomatosis with polyangitis? How do lesions appear?

A

Lesions move with time

Single or multinodular masses and cavitation

166
Q

What is the commonest cause of intersitial lung disease?

A

Idiopathic pulmonary fibrosis

167
Q

What is the pathological mechanism in idiopathic pulmonary fibrosis?

A

Uncertain

Inflammation causing activation of fibroblasts and thus collogen deposition

168
Q

Where in the lungs does idiopathic pulmonary fibrosis usually effect? CXR changes?

A

Bases

Ground glass appearence

169
Q

What spirometery change would be expected in idiopathic pulmonary fibrosis?

A

Restrictive pattern

170
Q

What would an ABG look like in severe idiopathic pulmonary fibrosis?

A

Type 1 resp failure (low o2) with hypocapnia (due to hyperventilation)

171
Q

What blood tests may be raised in idiopathic pulmonary fibrosis?

A

ANCA and RF

172
Q

Prognosis of idiopathic pulmonary fibrosis?

A

Mean survival 5 years

173
Q

Types of pneumothorax?

A

Spontanious primary - pristine lung
Spontanious secondary - underlying lung disease or >50 and smoker
Traumatic
Iatrogenic

174
Q

Complications (with signs) of a pneumothorax?

A

Tension pneumothorax - cardiac compromise

Pneumomediastinum - subcutanious emphysema and precodial crunching

175
Q

What is precordial crunching in a pneumothorax called?

A

Hammans sign

176
Q

Treatment options for a primary pneumothorax

A

2cm or breathless - aspirate and review in two weeks

If unsuccessful retry or drain

177
Q

Treatment options for a secondary pneumothroax

A

2cm, failed aspiration or breathless - drain

178
Q

Post discharge advice for pneumothorax?

A

No flying for 6 weeks

No diving ever

179
Q

Causes of brochiectasis?

A

Ciliary clearance - CF, primary ciliary dyskinesia
Autoimmune - RA, UC
Obstruction
Infection - pneumonia, tb, measles, pertussis
Immunodeficiency - primary, HIV

180
Q

Common infections in patients with bronchiectaisis

A 
Hamophilius influenza
Pseudomonas  aeruginsoa 
Moraxella cararrhalis 
Aspergillus
Candidia
181
Q

Symptoms of bronchiectasis?

A

Cough
Purulent sputum
Haemoptysis

182
Q

Signs of bronchiectasis

A

Clubbing
Crepitations
Wheeze

183
Q

What sort of ct should be used to look at suspected bronchiectasis? What may it show?

A

HRCT

Signet ring sign (thick and dilated bronchi with smaller vessels)

184
Q

Treatment options for bronchiectasis

A

Physiotherapy
Treatment and prophylactic antibiotics
Treat underlying condition
Consideration to bronchodilators and steroids

185
Q

How would an obstructive deficit appear on volume time spirometry and flow volume loop?

A

Low fev1 vs fvc

Scooped out appearance

186
Q

How does a restrictive deficit tend to appear on volume time spirometry and flow volume loop?

A

Low fvc and fev1 with preserved ratio

Narrowed appearance

187
Q

What fev1:fvc ratios represent mild, mod and severe pulmonary obstruction?

A

Mild 65-80%
Mod 50-65%
Severe

188
Q

What may drop prior to fev1:fvc in very mild obstructive disease? What is it?

A

Fef 25-75%

Average forced expiratory flow in the mid portion of fvc

189
Q

How do fixed, variable extrathoracic and variable intrathoracic obstructions appear on flow volume loops?

A

Fixed - flattening of insp and exp portion
Extrathoracic - flattening of insp portion
Intrathoracic - flattening of exp portion

190
Q

Examples of fixed airway obstructions?

A

Tumours

Tracheal stenosis

191
Q

Examples of variable extrathroacic airway obstructions?

A

Vocal cord dyskinesia

192
Q

Examples of variable interthoracic airway obstructions

A

Bronchiectaisis

193
Q

What is type 1 hypersensitivity?

A

Antigenic cross linking of IgE on mast cells triggering histamine release e.g. Anaphylaxis

194
Q

What is type 2 hypersensitivity?

A

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
Q

What is type 3 hypersensitivity?

A

IgG antibody antigen complex deposited in vessel wall with continued complement activation
E.g. Serum sickness, arthritis, glomerulonephritis

196
Q

What is type 4 hypersensitivity?

A

Th1 helper t cells activated by apc
Activation of macrophages
Inflammation
E.g. Contact dermatitis

197
Q

What testing can be done to look for type 1 hypersensitivity?

A

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
Q

Treatment of massive haemoptysis?

A 
Lie patient on side of suspected lesion
Tranexamic acid
Stop anticoagulation
Consider vit K
CT aortogram +/- embolisation
199
Q

Signs of massive PE

Management?

A

Hypotension/imminent cardiac arrest
Signs of right heart strain on ct/echo
Consider thrombolysis with altoplase

200
Q

Presentations of CF?

A

Meconium ileus - bowel blocked in newborns by secretions
Intestinal malabsorption - pancreatic insufficiency
Recurrent chest infections - bronchiectasis
Opportunistic newborn screening

201
Q

Lifestyle advice for CF patients?

A 
No smoking
Avoid other CF
Avoid people with infections
Avoid jacuzzis 
Avoid stables/compost (aspergillus)
202
Q

Three most common causes of massive haemoptysis

A

Tb
Bronchiectasis
Lung abcess

203
Q

What is the ONLY indication for urgent (pre diagnosis) chest drain in a pleural effusion? How would it be recognised on aspiration?

A

Empyema

pH of pleural fluid

204
Q

What are causes of transudate pleural effusions?

A 
Heart failure
Cirrhosis 
Hypoalbuminia (nephrotic syndrome)
Hypothyroidism 
PE
205
Q

What are causes of exudative pleural effusions?

A

Malignancy
Infections
Inflammation (RA, pancreatitis)
Lymphatic disorders

206
Q

What defines whether a pleural effusion is transudative or exudative?

A

Pleural proteins 30g/L

207
Q

What is the WHO performance scale?

A

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
Q

What is the MRC dysponea scale?

A

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
Q

Causes of OSA

A

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
Q

Issues with OSA

A

Sleep fragmentation
Disturbance of partners sleep!
Excessive daytime sleepiness
Hypertension

211
Q

What is used to assess daytime sleepiness in osa? What diagnostic tests are available?

A

Epworth sleepiness scale
Overnight pulse oximetry
Limited sleep study - movements, snoring, heart rate
Full sleep study - as above with EEG

212
Q

Management of OSA

A 
Weight loss
Sleeping position 
Decrease alcohol
Mandibular advancement devices
Nasal CPAP
Pharyngeal surgery
213
Q

Treatments of atelectasis

A

Cause dependant
Pulmonary physiotherapy - breathing and percussion
Mucus thinners
Broncoscopic opening

214
Q

What are the two main modes of niv? When are they useful?

A

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
Q

Why do copd and asthma cause difficulty in expiration?

A

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
Q

Contraindications to niv?

217
Q

Why does diarrhoea cause a normal anion gap acidosis?

A

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
Q

Causes of normal anion gap acidosis

A

Diarrhoea
Overenthusiastic na cl fluid therapy
Renal tubular acidosis

219
Q

Causes of metabolic alkalosis

A

Vomiting
Diuretics
Iatrogenic

220
Q

Treatment of hospital aquired pneumonia?

A

Piperacillin + gentamycin

221
Q

Types of aspergillus lung disease with brief description

A

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

IPE (17 decks)

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