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Respiratory Flashcards

1
Q

what is finger clubbing?

A
  1. bogginess/ increased fluctuance of nail bed
  2. loss of concave nail fold angle
  3. ↑ longitudinal and transverse curvature
  4. soft tissue expansion at distal phalanx
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2
Q

causes of clubbing

(cardiac)

A

CIA

Congenital cyanotica Heart disease

infective endocarditis

Atrial myxoma

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3
Q

Respiratory causes of clubbing?

A

Carcinoma: Bronchial, Mesothelioma

Chronic lung suppuration: empyema, abscess, bronchiectasis, Cystic fibrosis

Fibrosis: Idiopathic pulmonary fibrosis, TB

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4
Q

GI causes of clubbing?

A

Cirrhosis (liver)

Crohns/ UC

Coeliac Disease

Cancer: GI lymphoma

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5
Q

other general causes of clubbing?

A

familial

thyroid acropachy

upper limb AVMs or aneurysms -> unilateral clubbing

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6
Q

resp causes of cyanosis?

A

hypoventilation: COPD, MSK

decreased diffusion: Pulmonary oedema, fibrosing alveolitis

V/Q mismatch: PE, AVM

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7
Q

cardiac causes of cyanosis?

A

congenital: Tetralogy of Fallot’s, TGA

low Cardiac output: LVF, Mitral stenosis

Vascular: DVT, Raynaud’s

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8
Q

broncho vs lobar pneumonia?

A

Bronchopneumonia:

patchy consolidation of one or more lobes, of one or both lungs

(pus in many alveoli and adjacent air passages)

Lobar pneumonia:

acute inflammation of entire lobe

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9
Q

what are the 4 stages of lobar pneumonia?

A

congestion -> red hepatization -> grey hepatization -> resolution

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10
Q

what pathogens are mainly responsible for community acquired pneumonia?

A

strep pneumo

haemophilus influenzae

mycoplasma pneumo (esp in young adults- kids)

atypicals: moraxella, legionella, chlamydia

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11
Q

what pathogens are mainly responsible for hospital acquired pneumonia?

A

Gram -ve enterobacteria: e.g. pseudomonas, klebsiella

Staph aureus (usually MRSA)

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12
Q

what pathogens are mainly responsible for aspiration pneumonia?

A

anaerobes

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13
Q

what increases risk of aspiration pneumonia?

A

unsafe swallow

  • stroke, bulbar palsy, reduced GCS, achalasia, GORD
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14
Q

what are the main pathogens causing pneumonia in an immunocompromised patient?

A

PCP

TB

Fungi e.g. Aspergillus, cryptococcus

CMV/ HSV

+ the usual suspects

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15
Q

symptoms of pneumonia?

A

fever, rigors

malaise, anorexia

SOB

Cough, purulent sputum, haemoptysis

pleuritic pain

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16
Q

Signs of pneumonia?

A

↑HR, ↑RR

cyanosis

confusion

Consolidation: coarse crackles, decreased air entry, decreased expansion, dull percussion, bronchial breathing, pleural rub, increased vocal fremitus

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17
Q

Ix of pneumonia?

A

Bedside: Obs, Sputum Culture, Urine culture (Ag tests for legionella/ strep pneumo)

Bloods: FBC, U+E, WCC, CRP, Blood cultures, ABG (if SpO2 drops)

Imaging: CXR

Special:

  • Paired serological Abs for atypicals (chlamydia, mycoplasma, legionella)
  • Bronchoalveolar lavage
  • pleural tap
  • immunofluorescence (PCP)
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18
Q

what is the severity scoring system of pneumonia?

A

CURB-65

Confusion (AMTS ≤ 8)

Urea >7 mM

Resp Rate ≥30/ min

BP < 90 or ≤60

Age≥65

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19
Q

Mx of Pneumonia based on CURB65 risk stratification score?

A

0-1: outpatient care

2: inpatient / observation admission

≥ 3: inpatient admission, consider ITU

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20
Q

Mx of pneumonia?

A

Antibiotics

O2: SpO2 94-98%

Fluids

Analgesia

Chest physio

Consider ITU if shock, hypoxia, hypercapnia

Follow up at 6 wks with CXR

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21
Q

what empirical abx for mild CAP?

A

amoxicillin 500mg TDS PO for 5d

or

Clarithromycin 500mg BD PO 7d

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22
Q

what empirical abx for moderate CAP?

A

amoxicillin 500mg TDS and clarithro 500mg BD PO/IV

7 days

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23
Q

what empirical abx for severe CAP?

A

Co-amoxiclav 1.2g TDS IV (or cefuroxime)

AND Clarithro 500 mg BD IV

for 7-10 d

(add fluclox if staph suspected)

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24
Q

what empirical abx for chlamydial pneumonia?

A

doxycycline

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25
Q

what empirical abx for PCP?

A

co-trimoxazole

120 mg/kg daily in 2–4 divided doses for 14–21 days.

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26
Q

what empirical abx for legionella pneumonia?

A

clarithromycin + rifampicin

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27
Q

empirical abx for mild Hospital acquired pneumonia?

A

Co-amoxiclav 625mg PO TDS for 7d

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28
Q

empirical abx for severe HAP?

A

Tazocin ± vanc ± gent for 7d

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29
Q

who should get pneumovax?

A

Age >65

Immunosuppression: chemo, HIV, hyposplenism

DM

Chronic heart/ lung/ kidney/ liver failure

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30
Q

complications of pneumonia?

A

resp failure

hypotension + sepsis

AF

Pleural effusion

empyema

lung abscess

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31
Q

Type 1 vs Type 2 Respiratory Failure?

A

Type 1: PaO2 < 8 kPa, PaCO2 <6 kPa

Type 2: PaO2 < 8 kPa, PaCO2 > 6 kPa

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32
Q

what is empyema?

A

pus in the pleural cavity

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33
Q

tap of empyema will show?

A

turbid appearance

pH < 7.2

low glucose

high LDH

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34
Q

mx of empyema?

A

US guided chest drain + ABx

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35
Q

causes of lung abscess?

A

aspiration

bronchial obstruction: tumour, foreign bodt

septic emboli: sepsis, IVDU, RH endocarditis

pulmonary infarction

subphrenic/ hepatic abscess

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36
Q

features of lung abscess?

A

swinging fever

cough, purulent sputum, haemoptysis

pleuritic pain

malaise, weight loss

clubbing

empyema

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37
Q

ix of lung abscess?

A

bedside: sputum MCS
bloods: FBC, CRP, cultures
imaging: CXR - cavity w fluid level

consider CT and bronchoscopy

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38
Q

mx of lung abscess

A

aspiration

surgical excision

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39
Q

what is SIRS?

A

Inflammatory response of

2 or more of:

temp: >38 or <36

HR >90

RR >20 or PaCO2 < 4.6 kPa

WCC: > 12 or <4

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40
Q

what is sepsis?

A

SIRS + source of infection

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41
Q

what is severe sepsis?

A

sepsis w at least 1 organ dysfunction or hypoperfusion

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42
Q

what is septic shock?

A

severe sepsis with refractory hypotension

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43
Q

what is multiple organ dysfunction syndrome?

A

impairment of 2 or more organ systems

homeostasis cannot be maintained without therapeutic intervention

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44
Q

what is bronchiectasis?

A

airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection.

chronic infection of bronchi -> permanent dilatation, airway damage and recurrent infection

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45
Q

causes of bronchiectasis?

A

idiopathic - 50%

congenital:

CF, Kartagener’s, Young’s syndrome

Post-Infectious:

Measles, Pertussis, Pneumonia, TB, bronchiolitis

Immunodeficiency: brutons, CVID, IgA deficiency

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46
Q

what is young’s syndrome?

A

azoospermia + rhinosinusitis + bronchiectasis

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47
Q

symptoms of bronchiectasis

A

persistent cough with purulent sputum

haemoptysis

fever, weight loss

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48
Q

signs of bronchiectasis?

A

clubbing

coarse inspiratory creps

wheeze

purulent sputum

Situs inversus -> + Primary ciliary dyskinesia = Kartagener’s

Splenomegaly: immune deficiency

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49
Q

complications of bronchiectasis?

A

pneumonia

pleural effusion

pneumothorax

pulmonary HTN

Massive haemoptysis

amyloidosis

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50
Q

ix of bronchiectasis?

A

Bedside: Sputum MCS

Bloods: α1-AT level

Imaging: CXR - thickened bronchial walls

special: Spirometry - obstructive pattern

High resolution CT Chest

Bronchoscopy + mucosal biopsy: PCD

CF sweat test

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51
Q

what CXR findings with bronchiectasis?

A

thickened bronchial walls

‘tramlines and rings’

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52
Q

what CT chest findings with bronchiectasis?

A

dilated and thickened airways

saccular dilatations in clusters w pools of mucus

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53
Q

mx of bronchiectasis?

A

Chest physio: expectoration, drainage, pulm rehab

Abx for exacerbations

Bronchodilators: nebulised B agonists

Tx underlying cause:

e.g. CF, ABPA (Steroids), immune deficiency (IVIg)

surgery may be indicated in severe localised disease

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54
Q

pathogenesis of cystic fibrosis?

A

autosomal recessive

mutation in CFTR gene on chr 7

-> ↓ luminal Cl secretion and ↑ Na reabsorption -> viscous secretions

in sweat glands: decreased Cl and Na reabsorption -> salty sweat

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55
Q

features of CF in the neonate?

A

meconium ileus

FTT

rectal prolapse

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56
Q

features of CF in children/ young adults?

A

nasal polyps, sinusitis

recurrent chest infections, bronchiectasis

Pancreatic insufficiency: steatorrhoea, DM

gallstones

male infertility

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57
Q

signs of CF?

A

clubbing

cyanosis

bilateral coarse creps

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58
Q

what are the pathogens responsible for long term infections in CF?

A

pseudomonas aeruginosa

burkholderia cepacia

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59
Q

Diagnosis of CF?

A

Sweat Test: Na and Cl > 60 mM

genetic screening for common mutations

faecal elastase (tests pancreatic exocrine function)

immunoreactive trypsinogen (neonatal screening)

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60
Q

Ix of Cystic Fibrosis?

A

Bedside: Sputum MCS

Bloods: FBC, LFTs, clotting, Vit A/D/E/K levels, glucose lvl

Imaging:

CXR- bronchiectasis

Abdo US- fatty liver, cirrhosis, pancreatitis

Special: Spirometry - obstructive defect

Aspergillus serology (20% develop ABPA)

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61
Q

Mx of cystic fibrosis?

A

MDT: specialist nurse, physio, GP, dietician

Resp:

Chest Physio

Abx

mucolytics e.g. hypertonic saline, dornase alfa

bronchodilators

Vaccinations

GI:

pancreatic enzyme replacement

A/D/E/K supplements

insulin

ursodeoxycholic acid for impaired hepatic function

other:

tx of complications

fertility and genetic counselling

DEXA osteoporosis screen

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62
Q

mx of advanced lung disease with Cystic fibrosis?

A

Oxygen

Diuretics (Cor pulmonale)

NIV

heart/ lung transplantation

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63
Q

aspergillus can cause what kinds of pulmonary conditions?

A

asthma

Allergic bronchopulmonary aspergillosis

aspergilloma

invasive aspergillosis

extrinsic allergic alveolitis

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64
Q

What is Allergic Bronchopulmonary Aspergillosis?

A

T1 and T3 hypersensitivity reaction to aspergillus fumigatus

airway inflammation -> bronchiectasis

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65
Q

symptoms of Allergic bronchopulmonary aspergillosis?

A

wheeze

productive cough

dypsnoea

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66
Q

Ix of Allergic Bronchopulmonary Aspergillosis?

A

CXR: bronchiectasis

Aspergillus in sputum (black on silver stain)

Aspergillus skin test or IgE RAST

+ve Se precipitins (from previous exposure to aspergillus)

increased IgE and eosinophils

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67
Q

tx of allergic bronchopulmonary aspergillosis?

A

prenisolone 40mg/d + itraconazole for acute attacks

pred maintenance 5-10mg/d

bronchodilators for asthma

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68
Q

what is an aspergilloma?

A

fungus ball within a pre-existing cavity

e.g. TB or sarcoid

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69
Q

features of aspergilloma?

A

usually asymptomatic

can have haemoptysis

weight loss, lethargy

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70
Q

ix of aspergilloma?

A

CXR: round opacity - cavity, usually apical

sputum culture

+ve Se precipitins

Aspergillus skin test/ RAST

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71
Q

Mx of Aspergilloma?

A

consider excision for solitary lesions/ severe haemoptysis

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72
Q

complications of invasive aspergillosis

A

aflatoxins -> liver cirrhosis and HCC

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73
Q

risk factors for invasive aspergillosis?

A

immuno compromised pts: HIV, leukaemia

Post broad spec abx

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74
Q

Ix of invasive aspergillosis?

A

CXR: consolidation, abscess

Sputum MCS

BAL
+ve Se precipitins

serial Galactomannan assay

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75
Q

Mx of invasive aspergillosis?

A

voriconazole

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76
Q

local complications of lung cancers?

A

recurrent laryngeal n palsy (hoarseness)

phrenic nerve palsy (diaphragm paralysis)

SVC obstruction

Horner’s (Pancoast tumour)

AF

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77
Q

symptoms/ signs of SVC obstruction?

A

Pemberton’s sign: raise hands above head-> red face +/- blue + resp distress

Venous distention in the neck and distended veins in the upper chest and arms.

facial swelling / + upper limb oedema

collar of stokes (oedema of neck)

cough, difficulty breathing, headache

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78
Q

what is Horner’s syndrome?

A

miosis + partial ptosis + apparent anhidrosis + apparent enophthalmos

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79
Q

what may Pancoast tumour affect?

A

compression of a brachiocephalic vein, subclavian artery,

phrenic nerve, recurrent laryngeal nerve, vagus nerve

sympathetic ganglion (the stellate ganglion) -> Horner’s syndrome.

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80
Q

what paraneoplastic syndromes may lung cancers cause? (hormones)

A

SIADH -> low Na+ euvolaemic

PTHrP -> high Ca, bone pain

ACTH -> Cushing’s syndrome

Serotonin -> carcinoid (flushing, diarrhoea)

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81
Q

what is Trousseau’s syndrome?

A

aka Trousseau sign of malignancy

medical sign involving episodes of vessel inflammation due to blood clots which are recurrent or appearing in different locations over time (thrombophlebitis migrans)

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82
Q

Imaging Ix of lung cancer?

A

CXR - lesion, hilar enlargement, consolidation/ collapse, effusion, bony secondaries

Contrast CT for staging

consider CT brain for mets

PET-CT: for distant mets

radionucleotide bone scan

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83
Q

Bedside/ Bloods Ix for Lung Ca?

A

Bloods: FBC (anaemia), U+E, Ca2+, LFTs

Sputum cytology

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84
Q

Special Test Ix for Lung Ca?

A

Biopsy:

  • Bronchoscopy
  • Percutaneous FNA

Lung Function tests:

assess treatment fitness

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85
Q

Coin Lesion on CXR differential

A

foreign body

abscess

Granuloma: TB, sarcoid, wegener’s, RA

Neoplasia

Structural: AVM

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86
Q

what staging system used for NSCLC?

A

TNM Staging

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87
Q

Mx of Lung Ca?

A

MDT: resp physician, oncologist, radiologist, physio, OT, surgeon input, histopath, specialist nurses, palliative care

assess risk of operative mortality (co-morbidities, cardioresp function)

advise smoking cessation

tx depends on subtype of lung ca

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88
Q

What is Acute Respiratory Distress Syndrome?

A

life-threatening condition where the lungs can’t provide the body’s vital organs with enough oxygen.

inflammation due to infection/ injury -> ↑ capillary permeability -> pulmonary oedema -> breathing is difficult

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89
Q

symptoms of acute respiratory distress syndrome

A

SOB

Tachypnoea

confusion

cyanosis

bilateral fine creps

SIRS

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90
Q

Ix of ARDS?

A

CXR: bilateral perihilar infiltrates

Bloods: FBC, U+E, LFTs, clotting, amylase, CRP, Cultures, ABG

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91
Q

Dx of ARDS?

A

acute onset

CXR shows bilateral infiltrates

no evidence of congestive cardiac failure

PaO2:FiO2 <200

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92
Q

Mx of ARDS?

A

Admit to ITU for organ support and tx underlying cause

e.g. sepsis -> abx

support ventilation and circulation and nutritional support (e.g. enteral nutrition)

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93
Q

ventilation mx of ARDS if indicated?

ie. PaO2 <8 kPa despite 60% FiO2

or PaCO2 > 6kPa

A

PEEP (positive end-expiratory pressure)

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94
Q

what is Type 1 Respiratory failure?

what is it due to?

A

PaO2 < 8 and PaCO2 < 6

V/Q mismatch and diffusion failure

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95
Q

What is Type 2 Respiratory failure?

What is it due to?

A

PaO2<8 and PaCO2 >6

alveolar hypoventilation +/- V/Q mismatch

e.g. COPD, asthma, bronchiectasis

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96
Q

acute features of hypoxia?

A

SOB

agitation

confusion

cyanosis

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97
Q

features of chronic hypoxia?

A

polycythaemia

cor pulmonale (abnormal enlargement of R heart due to lung disease)

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98
Q

features of hypercapnia?

A

headache

flushing and peripheral vasodilatation

bounding pulse

flap (asterixis)

confusion-> coma

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99
Q

Mx of T1 resp failure?

A

tx underlying cause

give O2 to maintain SpO2 94-98%

assisted ventilation if PaO2 <8kPa despite 60% O2

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100
Q

Mx of T2 Resp failure?

A

Controlled O2 therapy at 24% O2 aiming for SpO2 88-92% and PaO2>8

Check ABG after 20 min

  • if PaCO2 steady or lower can increase FiO2 if necessary
  • if PaCO2 increases > 1.5 kPa, and pt still hypoxic, consider NIV or respiratory stimulant e.g. doxapram
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101
Q

what is the target SpO2 for those at risk of hypercapnic respiratory failure?

A

88-92%

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102
Q

Mx of pts at risk of hypercapnic resp failure?

A

Start O2 therapy at 24% (Blue venturi @2-4L/ min) and do an ABG

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103
Q

nasal prongs can delivery oxygen at what rate?

A

1-4L/ min = 24-40% O2

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104
Q

non rebreather mask can deliver oxygen at what rate?

A

reservoir bag allows delivery of high concentrations of O2

60-90% O2 at 10-15L

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105
Q

venturi mask can delivery oxygen at what rate?

A

delivers a known oxygen concentration to pts on controlled oxygen therapy

Yellow: 5%

White: 8%

Blue: 24%

Red: 40%

Green: 60%

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106
Q

what is asthma?

A

episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli

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107
Q

pathophysiology of acute asthma attack?

A

trigger causes Mast cell-Antigen interaction -> histamine release

-> bronchoconstriction, mucus plugs, airway mucosal swelling

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108
Q

triggers of asthma?

A

dust mites, pollen, animals

cold air, exercise, viral infection

smoking, pollution

Drugs: BB, NSAIDs

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109
Q

symptoms of asthma?

A

cough +/- sputum (often at night)

wheeze

SOB

diurnal variation w morning dipping

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110
Q

signs of asthma attack?

A

tachypnoea, tachycardia

decreased air entry, widespread polyphonic wheeze, hyperinflated chest

signs of steroid use

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111
Q

Ix of asthma?

A

Bloods: FBC (eosinophilia), high IgE, aspergillus serology

Bedside: PEFR monitoring/ diary (diurnal variation >20%)

CXR: hyperinflation

Spirometry: FEV1:FVC <0.75, 15% or more improvement in FEV1 w B-agonist

Atopy: Skin prick, RAST

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112
Q

Mx of asthma?

A

TAME

Technique for inhaler use

Avoidance: allergens, smoke, dust

Monitor: Peak flow diary (3x/d)

Educate: specialist nurse, need for tx compliance, emergency action plan

Drug ladder of asthma, start with SABA PRN

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113
Q

common clinical signs in PE?

A

Tachypnea (respiratory rate >16/min) - 96%

Crackles - 58%

Tachycardia (heart rate >100/min) - 44%

Fever (temperature >37.8°C) - 43%

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114
Q

Ix based on Well’s score-

if PE is likely (Wells > 4) - Mx?

if PE not likely (wells 4 or <) - Mx?

A

PE likely: immediate CTPA

if PE unlikely: D-dimer. if +ve -> CTPA

(if pt allergic to contrast/ renal impairment -> do V/Q scan)

if there is delay in ix, just give LMWH until scan is performed

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115
Q

classic ECG changes in PE?

A

sinus tachycardia

S1Q3T3

large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III

right BBB and right axis deviation are also associated with PE

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116
Q

risk factors for pseudomonas pneumonia?

A

bronchiectasis

CF

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117
Q

How to facilitate smoking cessation?

A

refer to specialist stop smoking service

Nicotine replacement:

  • Gum
  • Patches

Varenicline: selective partial nicotine receptor agonist

  • Recommended by NICE
  • 23% abstinence @ 1yr vs. 10% for placebo
  • Start while still smoking

Bupropion: also an option

 SpO2

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118
Q

definition of obstructive sleep apnoea?

A

intermittent closure/collapse of pharyngeal airway -> apnoeic episodes during sleep

119
Q

risk factors for obstructive sleep apnoea?

A

Obesity

male

smoker

alcohol

idiopathic pulm fibrosis

structural airway pathology: e.g. micrognathia

NM disease: e.g. MND

120
Q

Ix of obstructive sleep apnoea?

A

SpO2

Polysomnography is diagnostic (sleep studies)

121
Q

Mx of obstructive sleep apnoea?

A

↓wt.

Stop smoking

CPAP @ night via a nasal mask (1st line for mod/ severe)

intra-oral devices (e.g. mandibular advancement) if CPAP not tolerated and OSA mild

Surgery to relieve pharyngeal obstruction

  • Tonsillectomy
  • Uvulopalatpharyngoplasty
122
Q

features of obstructive sleep apnoea?

A

Nocturnal

Snoring

Choking, gasping, apnoeic episodes

Daytime

Morning headache

Somnolence

↓ memory and attention

Irritability, depression

123
Q

what is cor pulmonale?

A

RHF due to chronic Pulmonary HTN

124
Q

symptoms of cor pulmonale?

A

dyspnoea

fatigue

syncope

125
Q

signs of cor pulmonale?

A

raised JVP w prominent a wave

left parasternal heave (RVH)

loud P2 +/- S3

Murmurs:

  • PR: Graham Steell EDM
  • TR: PSM

Pulsatile Hepatomegaly

Fluid: ascites + peripheral oedema

126
Q

ix of cor pulmonale?

A

Bloods: FBC, U+E, LFTs, ESR, ANA, RF

ABG: hypoxia +/- hypercapnoea

CXR: enlarged R atrium + ventricle, prominent pulmonary arteries

ECG: P pulmonale + RVH

Echo: RVH, TR, increased pulmonary artery pressure

Spirometry

Right heart catheterisation

127
Q

Mx of cor pulmonale?

A

Tx underlying condition

decreased pulmonary vascular resistance:

  • long term o2 therapy
  • CCB e.g. nifedipine
  • Sildenafil (PDE-5 inhibitor)
  • prostacycline analogues

Cardiac failure: ACEi + BB (caution if asthma), diuretics

heart- Lung transplant

128
Q

definition of pulmonary HTN?

A

PA pressure > 25 mmHg

129
Q

Causes of pulmonary Hypertension?

A

Left heart disease:

  • mitral stenosis
  • mitral regurg
  • left ventricular failure
  • L->R shunt

Lung Parenchymal Disease:

  • chronic hypoxia -> hypoxic vasoconstriction, perivascular parenchymal changes
  • COPD
  • Asthma: severe, chronic
  • interstitial lung disease
  • CF, bronchiectasis

Pulmonary Vascular Disease:

  • idiopathic pulm HTN
  • pulm vasculitis: SLE, scleroderma, Wegener’s
  • Sickle cell
  • PE
  • Portal HTN

Hypoventilation:

Obstructive sleep apnoea

morbid obesity

Thoracic cage abnormality: kyphosis, scoliosis

Neuromuscular: MND, MG, polio

130
Q

Ix of Pulm HTN?

A

ECG: P pulmonale, RVH, R Atrial Deviation

Echo: Severity of TR, RA/RV enlargement, ventricular dysfunction, valve disease

Right heart catheterisation: Gold St

131
Q

what is the gold st ix for pulmonary HTN?

A

right heart catheterisation

  • mean pulmonary artery pressure
  • pulmonary vascular resistance
  • Cardiac Output
  • vasoreactivity testing to guide tx
132
Q

what is extrinsic allergic alveolitis?

A

acute allergen exposure in sensitised pts

chronic exposure -> granuloma formation and obliterative bronchiolitis

133
Q

causes of extrinsic allergic alveolitis?

A

Bird Fancier’s lung: proteins in bird droppings

farmer’s / mushroom worker’s

Malt worker’s lung: Aspergillus clavatus

134
Q

features of extrinsic allergic alveolitis?

A

4-6h post exposure:

fever, rigors, malaise

dry cough, dyspnoea

crackles (no wheeze)

chronic:

  • increasing dyspnoea
  • weight loss
  • T1RF
  • cor pulmonale
135
Q

mx of extrinsic allergic alveolitis?

A

avoid exposure

steroids: acute/ long-term

compensatoin may be payable

136
Q

ix of extrinsic allergic alveolitis?

A

bloods: neutrophilia, raised ESR, +ve se precipitins

CXR: upper zone fibrosis -> honeycomb lung

Spirometry: Restrictive defect

Bronchoalveolar lavage: raised lymphocytes and mast cells

137
Q

features of coal workers pneumoconiosis?

A

progressive massive fibrosis

presents as progressive dyspnoea and chronic bronchitis

CXR: upper zone fibrotic masses

138
Q

features of silicosis

A

assoc w quarrying, sand blasting

upper zone reticular shadowing and egg shell calcification of hilar nodes

139
Q

Features of asbestosis?

A

demolition and ship building

basal fibrosis, pleural plaques

increased risk of mesothelioma

140
Q

featiueres of mesothelioma?

A

chest pain, weight loss, clubbing, recurrent effusions, dyspnoea

CXR: pleural effusions, thickening

Dx by histology of pleural biopsy

141
Q

diagnosis of mesothelioma?

A

histology of pleural biopsy

142
Q

epidemiology of idiopathic pulmonary fibrosis?

A

commonest cause of interstitital lung disease

middle age

M>F 2:1

assoc w other AI disease in 30%

143
Q

presentation of idiopathic pulmonary fibrosis?

A

signs:

clubbing

cyanosis

crackles: fine, end inspiratory

symptoms:

dyspnoea

dry cough

malaise, weight loss

arthralgia

obstructive sleep apnoea

144
Q

complications of idiopathic pulmonary fibrosis?

A

increased risk of lung ca

T2RF and cor pulmonale

145
Q

Ix for idiopathic pulmonary fibrosis

A

Bloods:

raised CRP, raised IG, ANA+ (30%), RF+ (10%)

ABG- low PaO2, high PCO2

CXR:

decreased lung vol, bilat lower zone reticulonodular shadowing

honey comb lung

High resolution CT: - more sensitive, diagnostic

Spirometry: restrictive defect, decreased transfer factor (impaired gas exchange)

BAL: may indicated disease activity

raised lymphocytes: good prognosis

raised polymorphonuclear cells or eosinophils: poor

146
Q

mx of idiopathic pulmonary fibrosis?

A

supportive care:

stop smoking

pulmonary rehabilitation

pirfenidone (an antifibrotic agent) may be considered

o2 therapy

palliation

tx symptoms of HF

lung transplant offers only cure

147
Q

principal features of interstitial lung disease?

A

dyspnoea

dry cough

abnormal CXR/ CT

Restrictive spirometry

148
Q

causes of interstitial lung disease?

A

environmental: silicosis, asbestosis

Drugs: Bleomycin, Amiodarone, Nitrofurantoin, Sulfasalazine, methotrexate

Hypersensitivity: EAA

Infection: TB, viral, fungi

systemic disease: RA, sarcoidosis, SLE, UC, ank spond

Idiopathic: IPF

149
Q

interstitial lung disease

which causes mainly affect the upper zone?

A

A PENT(house)

Aspergillosis: ABPA

Pneumoconiosis: coal, silica

Extrinsic allergic alveolitis

Negative, sero-arthropathy

TB

150
Q

interstitial lung disease

what causes lower zone fibrosis?

A

STAIR(case down)

Sarcoidosis (mid zone)

Toxins: Bleomycin, Amiodarone, Nitrofuran, Sulfasalazine, Methotrexate

Asbestosis

Idiopathic pulm fibrosis

Rheum: RA, SLE, Scleroderma, Sjogrens,

151
Q

what is sarcoidosis?

A

multisystem granulomatous disorder of unknown cause

age: 20-40

F>M

Afro caribbean

152
Q

features of sarcoidosis?

A

may present incidentally on CXR

acute sarcoidosis: fever, polyarthralgia, erythema nodosum, LNs

GRANULOMAS

General: fever, anorexia, weight loss, fatigue, Lymphadenopathy

Resp: fibrosis

Arthalgia: polyarthralgia, dactylitis

Neuro: polyneuropathy e.g. Bell’s

Urine: high Ca -> renal stones

Low hormones: pituitary dysfunction

Opthal: uveitis, keratoconjunctivitis, sicca/sjogrens

Myocardial: restrictive cardiomyopathy secondary to granulomas + fibrosis

Abdo: hepato splenomegaly + cholestatic LFTs

Skin: Erythema nodosum, Lupus pernio

153
Q

Differentials for Bilateral hilar lymphadenopathy?

A

Sarcoidosis

Infection: TB, mycoplasma

malignancy: lymphoma, carcinoma

interstitial disease: EAA, silicosis

154
Q
A

Bilateral Hilar Lymphadenopathy

155
Q

Ix of Sarcoidosis?

A

Bloods:

high ESR, Ca, Serum ACE, Ig, LFTs

CXR, CT, MRI

Spirometry: restrictive

tissue biopsy: diagnostic- non caseating granulomas

opthal assessment

156
Q

mx of Sarcoidosis?

if Bilateral Hilar Lymphadenopathy but asymptomatic

157
Q

mx of acute sarcoidosis?

A

usually resolves spontaneously

bed rest and NSAIDs

158
Q

mx of chronic sarcoidosis?

A

Steroids: pred 40mg/d for 4-6 wks

additional immunosuppression: methotrexate, ciclosporin, cyclophosphamide

159
Q

how to classify pleural effusion as exudate or transudate?

A

Effusion Protein < 25 g/L = transudate

Effusion protein > 35 g/L = exudate

Between 25-35: apply Light’s Criteria

Lights criteria

  • an exudate has one of:
    1. Effusion: serum protein ratio > 0.5
    2. Effusion: serum LDH ratio > 0.6
    3. Effusion LDH is 0.6 x ULN
160
Q

what is acute respiratory distress syndrome?

A

caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema

mortality ~ 40%

161
Q

causes of ARDS (acute resp distress syndrome)?

A

infection; sepsis, pneumonia

massive blood transfusion

trauma

smoke inhalation

pancreatitis

cardio-pulm bypass

162
Q

Key Ix of Acute Resp Distress Syndrome?

A

ABG

CXR: pulmonary oedema (bilat infiltrates)

non cardiogenic (Pulm art wedge pressure if in doubt)

163
Q

Mx of acute resp distress syndrome?

A

due to severity of condition -> ITU

oxygen/ ventilation to treat low O2

General organ support: e.g. vasopressors

tx of underlying cause e.g. abx for sepsis

164
Q

what is Light’s criteria?

A

to determine if pleural effusion is transudate or exudate if in doubt ( protein = 25-35 g/L)

an exudate has one of:

effusion: serum protein ratio > 0.5
effusion: serum LDH ratio > 0.6

effusion LDH is 0.6 x upper limits of normal serum LDH

165
Q

causes of exudative pleural effusion?

A

due to increased cap permeability

infection: pneumonia, TB
neoplasm: bronchial, lymphoma, mesothelioma

Inflammation: RA, SLE

infarction

166
Q

causes of transudative pleural effusion?~

A

due to increased cap hydrostatic or decreased oncotic pressure

CCF

Renal failure

low albumin: nephrotic synd, liver failure, enteropathy

hypothyroidism

Meig’s Syndrome: right Pleural effusion, ascites, ovarian fibroma

167
Q

Ix of Pleural effusion?

A

Imaging: PA CXR

US recommended: increases likelihood of successful pleural aspiratoin and is sensitive for detecting pleural fluid septations

contrast CT: to ix underlying cause

Pleural aspiration:

sent for pH, protein, LDH, cytology and microbiology

168
Q

raised amylase in pleural effusion aspiration suggests?

A

pancreatitis

oesophageal perforation

169
Q

heavy blood staining in pleural effusion aspiration suggests?

A

mesothelioma,

PE

TB

170
Q

low glucose in pleural effusion aspiration suggests?

171
Q

Mx of pleural infection?

A

pleural effusion in assoc w sepsis or pulmonic illness need diagnostic pleural fluid samplng

  • if fluid is purulent or tubid/ cloudy -> chest tube to allow drainage
  • if fluid is clear but pH<7.2 -> chest tube should be placed
172
Q

mx of recurrent pleural effusion?

A

recurrent aspiration

pleurodesis

indwelling pleural catheter

drug mx to alleviate symptoms e.g. opioids to relieve dyspnoea

173
Q

mx of pleural effusion?

A

tx underlying cause

may use drainage if symptomatic

  • w repeated aspiration or chest tube

chemical pleurodesis if recurrent malignant effusion

persistent effusions may require surgery

174
Q

features of pleural effusion?

A

symptoms: asymptomatic, SOB, pleuritic chest pain

Signs:

tracheal deviation away from effusion, decreased expansion

stony dull percussion

decreased breath sounds, bronchial breathing just above effusion

decreased vocal fremitus

signs of underlying cause e.g. cancer, HF

175
Q

definition of pneumothorax?

A

accumulation of air in the pleural space w secondary lung collapse

176
Q

types of pneumothorax?

A

closed: intact chest wall. air from lung -> pleural cavity
open: defect in chest wall. exterior -> pleural cavity
tension: air enters pleural cavity through one way valve and cannot escape -> mediastinal compression

177
Q

Causes of pneumothorax?

A

Spontaneous:

1º - no underlying lung disease. young thin men (ruptured subpleural bulla), smokers

2º - underlying lung disease

e. g. COPD, marfans, ehlers danlos, pulm fibrosis, sarcoidosis
trauma: penetrating, blunt +/- rib fractures
iatrogenic: subclavian CVP line insertion, Positive pressure ventilation

178
Q

features of pneumothorax?

A

symptoms:

sudden onset SOB, pleuritic chest pain

signs:

chest: reduced expansion, resonant percussion, decreased breath sounds, low vocal resonance
tension: raised JVP, mediastinal shift

179
Q

ix of pneumothorax?

A

ABG

US

CXR: expiratory film

  • Translucency + collapse (2cm rim = 50% vol loss)
  • Mediastinal shift (away from PTX)
  • Surgical emphysema
  • Cause: rib #s, pulmonary disease (e.g. bullae)
180
Q

Mx of tension pneumothorax?

A

A-> E approach

Resus

no CXR

straight up large bore venflon into 2nd ICS, Mid clavicular line

insert chest drain

181
Q

mx of traumatic pneumothorax?

A

A to E resus

analgesia: e.g. morphine

3 sided wet dressing if sucking

insert chest drain

182
Q

Mx of primary pneumothorax?

A

A to E approach

CXR

  • > SOB and or rim bigger than 2 cm?
  • > NO -> discharge
  • > yes -> aspiration successful? -> Yes -> discharge
  • > NO (>2cm or still SOB): Chest drain
183
Q

Mx of secondary pneumothorax?

A

A to E resus

CXR

SOB and >50 yo and rim >/= 2 cm? -> yes -> intercostal drain

  • > no -> aspiration successful? -> no -> intercostal drain
  • > yes -> admit for 24h
184
Q

Causes of pulmonary embolism?

A

usually from DVTs in proximal leg or iliac veins

rarely: septic emboli in right sided endocarditis, or RV post MI

185
Q

risk factors of PE?

A

Sex: female

pregnancy

increased age

surgery

malignancy

oestrogen: OCP/ HRT

immobility

past hx

colossal size

antiphospholipids abs

lupus anti coagulant

186
Q

features of PE?

A

symptoms: dyspnoea, pleuritic pain, haemoptysis, syncope
signs: fever, tachycardia, tachypnoea

RHF: hypotension, raised JVP, loud P2

187
Q

Ix for PE?

A

Bloods

ABG

CXR

ECG: sinus tachycardia, RBBB, Right ventricular strain (rarely S1Q3T3)

Doppler US for DVT

CTPA

188
Q

diagnosis of PE?

A

assess probability using Wells Score

low probability -> perform D dimers

negative -> excludes PE

+ve -> CTPA

high probability -> CTPA

189
Q

prevention of PE?

A

risk assessment of all pts

TEDS

prophylactic LMWH

early mobilisation after surgery

avoid OCP/ HRT if @ risk

190
Q

Mx of PE?

A

A to E approach

Airway: Sit up, 100% O2 via non rebreather mask

Analgesia: morphine + metoclopramide

if critically ill w massive PE -> consider thrombolysis (e.g. alteplase 50mg bolus stat)

LMWH e.g. enoxaparin SC

Circulation: <90 -> fluid bolus

If BP still low: consider inotropes (ie. Dobutamine, Norad)

cont LMWH until INR >2

target INR 2-3

duration of warfarin: remedial cause 3 mo

no identifiable cause 6 mo

on going cause: indefinite

191
Q

Causes of acute exacerbation of COPD?

A

viral URTI

bacterial infections

192
Q

features of acute exacerbation of COPD?

A

cough + sputum

breathlessness

wheeze

193
Q

ix of acute exacerbations of COPD?

A

Bloods

Sputum culture

PEFR

CXR

ECG

194
Q

discharge mx for acute exacerbation of COPD?

A

spirometry

establish optimal maintenance therapy

GP and specialist follow up

prevention using home oral steroids and abx

pneumococcal and flu vaccine

home assessment

195
Q

mx of acute exacerbation of COPD?

A

A to E approach

Airway: sit up, 24% O2 via Venturi mask (aim SpO2 88-92)

nebulised bronchodilators: salbutamol + ipratropium bromide air driven via nasal specs

Steroids: IV hydrocortisone then PO prednisolone 30 mg for 7-14 days

Abx if evidence of infection

NIV if no response: if PH < 7.35 and or RR >30

consider invasive ventilation if pH <7.26

196
Q

definition of COPD?

A

airway obstruction: FEV1 <80%, FEV1:FVC <0.70

Chronic bronchitis: cough and sputum production on most days for 3 mo of 2 successive years

Emphysema: histological diagnosis of enlarged air spaces distal to terminal bronchioles w destruction of alveolar walls

197
Q

causes of COPD?

A

smoking

pollution

a1 antitrypsin

198
Q

signs of COPD?

A

tachypnoea

prolonged expiratory phase

hyperinflation: decreased cricosternal distance (normal = 3 fingers), loss of cardiac dullness, displaced liver edge

wheeze

may have early inspiratory crackles

cyanosis

cor pulmonale: raised JVP, oedema, loud P2

signs of steroid use

199
Q

features of emphysema?

A

pink puffers

increased alveolar ventilation -> breathless but not cyanosed

normal or near normal PaO2

normal or low PaCO2

Progress -> T1RF

200
Q

Features of chronic bronchitis?

A

Blue bloaters

low alveolar ventilation -> cyanosed but not breathless

low PaO2 and high PaCO2: rely on hypoxic drive

progress -> T2RF and cor pulmonale

201
Q

complications of COPD?

A

acute exacerbations +/- infection

polycythaemia

pneumothorax (ruptured bullae)

cor pulmonale

lung ca

202
Q

what is the mMRC dyspnoea score?

A
  1. Dyspnoea only on vigorous exertion
  2. SOB on hurrying or walking up stairs
  3. Walks slowly or has to stop for breath
  4. Stops for breath after <100m / few min
  5. Too breathless to leave house or SOB on dressing
203
Q

Ix of COPD?

A

BMI

Bloods: FBC, a1-AT, ABG

CXR: hyperinflation (>6 ribs anteriorly), prominent pulm arteries, bullae

ECG: P Pulmonale, RVH, RAD

Spirometry: FEV1<80%, FEV1:FVC <0.70

echo: pulm HTN

204
Q

how to determine severity of COPD?

A

Mild: FEV1 >80% (but FEV/FVC <0.7 and symptomatic)

Mod: FEV1 50-79%

Severe: FEV1 30-49%

Very Severe: FEV1 < 30%

205
Q

Mx of COPD?

A

general mx:

stop smoking

pulmonary rehabilitation

annual Influenze and one off pneumococcal vaccine

Review 1-2x/ yr

Mucolytics: if chronic productive cough

e.g. carbocisteine

SABA and or SAMA (ipratropium) PRN

does pt have asthmatic features?

-no asthmatic features: add LABA and LAMA

Asthmatic features/features suggesting steroid responsiveness ->

LABA + inhaled corticosteroid (ICS) or

triple: LAMA + LABA + ICS

206
Q

what general measures should be instigated in mx of COPD?

A

Stop smoking:

  • Specialist nurse
  • Nicotine replacement therapy
  • Bupropion, varenicline (partial nicotinic agonist)
  • Support programme

Pulmonary rehabilitation / exercise

Rx poor nutrition and obesity
Screen and Mx comorbidities e.g. cardiovasc, lung Ca, osteoporosis

Influenza and pneumococcal vaccine

Review 1-2x/yr

Air travel risky if FEV1<50%

207
Q

When is long term oxygen therapy used in COPD?

A

aim: PaO2 ≥8 for ≥15h / day (↑ survival by 50%)

Clinically stable non-smokers w PaO2 <7.3 (stable on two occasions >3wks apart)

PaO2 7.3 – 8 + PHT / cor pulmonale / polycythaemia / COPD

/ nocturnal hypoxaemia

Terminally ill pts.

208
Q

when is surgery indicated in COPD?

A

Recurrent pneumothoraces

Isolated bullous disease

Lung volume reduction

209
Q

Mx of persistent exacerbations or breathless in COPD?

A

LABA+LAMA+ICS

Roflumilast / theophylline (PDIs) may be considered

Consider home nebs

210
Q

Mx of exacerbations or persistent breathlessness of COPD?

A

FEV1 ≥50%: LABA or LAMA (tiotropium) (stop SAMA)

FEV1 <50%: LABA+ICS combo or LAMA

211
Q

hx of acute severe asthma?

A

Precipitant: infection, travel, exercise?

Usual and recent Rx?

Previous attacks and severity: ICU?

Best PEFR?

Medication compliance

212
Q

Ix in acute asthma?

A

PEFR

ABG

  • PaO2 usually normal or slightly ↓
  • PaCO2 ↓
  • If PaCO2 ↑: send to ITU for ventilation

FBC, U+E, CRP , blood cultures

213
Q

features of severe asthma?

A

any one of:

  • PEFR <50%
  • RR>25
  • HR >110
  • Can’t complete sentence in one breath
214
Q

features of life threatening asthma?

A

any one of:

PEFR <33%

SpO2 <92%, PCO2 >4.6kPa, PaO2 <8kPa

Cyanosis

Hypotension

Exhaustion, confusion

Silent chest, poor respiratory effort

Tachy-/brady-/arrhythmias

215
Q

admission criteria for acute asthma attack?

A

Life-threatening attack

Feature of severe attack persisting despite initial Rx

May discharge if PEFR > 75% 1h after initial Rx

216
Q

Mx of Acute Asthma?

A

A to E approach

  1. Sit-up
  2. 100% O2 via non-rebreathe mask (aim for 94-98%)
  3. Nebulised salbutamol (5mg) and ipratropium (0.5mg)
  4. Hydrocortisone 100mg IV or pred 50mg PO (or both)
  5. Write “no sedation” on drug chart
217
Q

mx if life threatening asthma?

after O2, salbutamol, ipratropium, hydrocort have been given

A

Inform ITU

MgSO4 2g IVI over 20 min

Nebulised salbutamol every 15 min (monitor ECG)

218
Q

mx of acute asthma after acute mx and improving?

A

monitor SpO2 @ 92-94, PEFR

Continue Prednisolone 50mg OD for 5 days

Nebulised salb every 4 hrs

219
Q

what mx of acute asthma if no improvement after treatment?

A

IV mx:

Nebulised salbutamol every 15min (monitor ECG)

Continue ipratropium 0.5mg 4-6hrly

MgSO4 2g IVI over 20min

Salbutamol IVI 3-20ug/min

Consider aminophylline
- Load: 5mg/kg IVI over 20min, Unless already on theophylline

  • Continue: 0.5mg/kg/hr
  • Monitor levels

ITU transfer for invasive ventilation

220
Q

Asthma Treatment Ladder for adults?

A
  1. inhaled SABA reliever therapy PRN
  2. is use SABA 3x/wk or nocturnal symptoms -> inhaled corticosteroid as preventer therapy
    ie. low dose beclometasone 100-400 mcg bd
  3. if uncontrolled, offer oral Leukotriene receptor antagonist w ICS

or LABA (Salmeterol) w ICS

*if LTRA not effective, -> LABA

  1. if LABA w ICS ineffective -> maintenance and reliever therapy (MART)

a single inhaler containing both ICS and a fast-acting LABA, which is used for both daily maintenance therapy and the relief of symptoms as required.

  1. If MART ineffective -> increase inhaled steroid to moderate maintenance dose
  2. consider a trial of an additional drug (for example, a muscarinic receptor antagonist or theophylline)

or high dose inhaled steroids

  1. oral steroids
221
Q

mx of bronchiectasis?

A

Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation. After assessing for treatable causes (e.g. immune deficiency) management is as follows:

  • physical training (e.g. inspiratory muscle training) - has a good evidence base for patients with non-cystic fibrosis bronchiectasis
  • postural drainage
  • antibiotics for exacerbations + long-term rotating antibiotics in severe cases
  • bronchodilators in selected cases
  • immunisations
  • surgery in selected cases (e.g. Localised disease)
222
Q

most common organism isolated from pts w bronchiectasis?

A

haemophilus influenzae

223
Q

indications for surgery in bronchiectasis?

A

uncontrollable haemoptysis

localised disease

224
Q

ix that supports diagnosis of asthma?

A

fractional exhaled nitric oxide (FeNO) testing:

level of 40 parts per billion (ppb) or higher

Spirometry:

FEV1/FVC ratio <70% suggests airflow limitation

Bronchodilator reversibility:

improvement in FEV1 of 12% or >, together with an increase in vol of at least 200 mL in response to beta-2 agonists or corticosteroids is regarded as a positive result

Variable peak expiratory flow (PEF) readings:

more than 20% variability

225
Q

ix of pneumonia according to curb score?

A

chest x-ray

in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests

CRP monitoring is recommend for admitted patients to help determine response to treatment

226
Q

mx of high-severity community acquired pneumonia?

A

NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide

227
Q

what is Lofgrens syndrome?

A

Lofgren’s syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis

228
Q

what is Mikulicz syndrome?

A

In Mikulicz syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma

229
Q

what is Heerfordt’s syndrome?

A

Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

231
Q

mx of COPD when symptoms not controlled on SABA/SAMA?

No asthmatic features/features suggesting steroid responsiveness

A

add a long-acting beta2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA)

232
Q

mx of COPD when not controlled on SABA/ SAMA?

Asthmatic features/features suggesting steroid responsiveness

A

LABA + inhaled corticosteroid (ICS)

if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS

233
Q

mx of COPD after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy?

A

oral theophylline

234
Q

mx of cor pulmonale secondary to COPD?

A

use a loop diuretic for oedema, consider long-term oxygen therapy

235
Q

what is considered low dose of inhaled corticosteroid?

what is high?

A

For adults:

<= 400 micrograms budesonide or equivalent = low dose

400 micrograms - 800 micrograms budesonide or equivalent = moderate dose

> 800 micrograms budesonide or equivalent= high dose.

236
Q

features of granulomatosis w polyangiitis (aka Wegener’s)?

A

upper respiratory tract: epistaxis, sinusitis, nasal crusting

lower respiratory tract: dyspnoea, haemoptysis

rapidly progressive glomerulonephritis (‘pauci-immune’, 80% of patients)

saddle-shape nose deformity

also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions

237
Q

ix of Granulomatosis w polyangiitis?

A

cANCA+ve

CXR: cavitating lesions

renal biopsy: epithelial crescents in Bowman’s capsule

238
Q

mx of granulomatosis w polyangiitis?

A

steroids

cyclophosphamide (90% response)

plasma exchange

239
Q

prevention of acute mountain sickness?

A

gain altitude at no more than 500 m per day

acetazolamide (a carbonic anhydrase inhibitor) is widely used to prevent AMS and has a supporting evidence base

treatment: descent

240
Q

mx of high altitude cerebral oedema?

A

descent

dexamethasone

241
Q

mx of high altitude pulmonary edema?

A

descent

nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors* (by reducing systolic pulmonary artery pressure)

oxygen if available

242
Q

white out of hemithorax but tracheal central?

A

Consolidation
Pulmonary oedema (usually bilateral)
Mesothelioma

243
Q

white out of hemithorax w trachea pulled towards white out?

A

Pneumonectomy
Complete lung collapse e.g. endobronchial intubation
Pulmonary hypoplasia

244
Q

white out of hemithorax w trachea pushed away from the white out?

A

Pleural effusion
Diaphragmatic hernia
Large thoracic mass

245
Q

features of bronchiectasis?

A

may have a history of previous infections (e.g. Tuberculosis, measles), bronchial obstruction or ciliary dyskinetic syndromes e.g. Kartagener’s syndrome

affected pts may produce large amounts of purulent sputum

Clubbing

246
Q

when should long term oxygen therapy be offered to COPD pts?

A

a pO2 of < 7.3 kPa

or to those with a pO2 of 7.3 - 8 kPa and one of the following:

secondary polycythaemia

nocturnal hypoxaemia

peripheral oedema

pulmonary hypertension

247
Q

what interventions improve survival in COPD?

A

smoking cessation

LTOT in those who fit criteria

lung volume reduction surgery in selected patients

248
Q

contraindications to lung cancer surgery?

A

stage IIIb or IV (i.e. metastases present)

FEV1 < 1.5 litres is considered a general cut-off point*

malignant pleural effusion

tumour near hilum

vocal cord paralysis

SVC obstruction

249
Q

what are the oxygen saturation targets for an acutely ill pt w COPD?

250
Q

ACE levels in sarcoidosis?

251
Q

what ectopic hormones are small cell lung ca assoc w?

A

ectopic ADH, ACTH secretion

ADH -> hypoNa

ACTH -> Cushings

Lambert-Eaton syndrome: antibodies to voltage gated calcium channels

252
Q

mx of small cell lung ca?

A

patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery

most patients with limited disease receive a combination of chemotherapy and radiotherapy

patients with more extensive disease are offered palliative chemotherapy

253
Q

most common organism causing acute exacerbation of COPD?

A

haemophilus influenzae

then sometimes: strep pneumo, moraxella catarrhalis

254
Q

when are oral abx indicated during acute exacerbation of COPD

A

if sputum is purulent or there are clinical signs of pneumonia’

255
Q

reason for inhaled corticosteroid therapy in COPD?

A

reduced frequency of exacerbations

256
Q

features of Eosinophilic granulomatosis with polyangiitis

(aka Churg- Strauss)

A

ANCA associated small-medium vessel vasculitis.

asthma

blood eosinophilia (e.g. > 10%)

paranasal sinusitis

mononeuritis multiplex

pANCA positive in 60%

Leukotriene receptor antagonists may precipitate the disease

257
Q

mx of ascites in pts with cirrhosis?

A

Spironolactone- aldosterone antagonist

258
Q
A

Nasogastric tube

  • feeding NG tube used for enteral nutrition
  • fine bore and is soft unlike the Ryle’s NG tube which is wide bore

indicated in oesophageal obstruction

contraindicated in: basal skull fracture, facial traume or pt refusal

259
Q
A

Endotracheal tube

indicated: to acquire a definitive airway in elective/ emergency situations
features: cuffed - secured tube + prevents aspiration

uncuffed- children, avoid damaging larynx

size: female- 7.5, male - 8.5

double lumen: allow single lung ventilation, used in thoracic surgery

radio-opaque line: blue

260
Q
A

iGel: laryngeal mask airway

non definitive airway, may also be used in emergency situation

provide an anatomical impression fit over the laryngeal inlet

(inflatable cuff to create a seal)

method:

cuff is deflated and lubricated w aquagel

inserted w open end pointing down towards the tongue

sits in orifice over the larynx

cuff inflated and tube secured w tape

complications: dislodgement, leak, pressure necrosis in airway, aspiration

261
Q
A

Guedel Airway (oropharyngeal)

airway adjunct used in pts w impaired LOC to maintain a patent airway

measure from incisors to angle of mandible

insert upside down and rotated once in the oral cavity

complications: oropharyngeal trauma, gagging -> vomiting

262
Q
A

nasopharyngeal airway

  • airway adjunct used in pts w impaired LOC to maintain patent airway
    method: sized lateral edge of nostril to trigus of ear

safety pin and flared end prevents the tube becoming irretrievable

complications: bleeding (trauma to nasal mucosa), intracranial placement
contraindications: absolutely contraindicated in pts w facial injuries or evidence of basal skull #

263
Q
A

Ryles nasogastric tube

indicated for draining the stomach (drip and suck), pts w persistent vomiting e.g. pancreatitis

features: wire bore, stiffer, radio opaque line

264
Q
A

3 way irrigation foley catheter

  • indication: irrigate bladder in pts at risk of clot retention e.g. pts w haematuria or after TURP
    features: 3 ports = balloon inflation, drainage (middle), irrigation
265
Q

causes of horners syndrome?

A

Central (anhidrosis of face, arm and trunk):

syringomyelia

MS

Brain tumour

stroke

Preganglionic (anhidrosis of face):

cervical rib

pancoast tumour

trauma (Klumpkes)

Postganglionic (no anhidrosis):

carotid artery aneurysm/ dissection

cavernous sinus thrombosis

267
Q

most common cause of infective exacerbations of COPD?

A

Haemophilus influenzae

tx: amoxicillin or a tetracycline together with prednisolone.

268
Q

key indications for non invasive ventilation?

A

COPD with respiratory acidosis pH 7.25-7.35*

type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea

cardiogenic pulmonary oedema unresponsive to CPAP

weaning from tracheal intubation

270
Q

Assessment of sleepiness in obstructive sleep apnoea?

A

Epworth Sleepiness Scale - questionnaire completed by patient +/- partner

Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)

271
Q

monitoring of which marker determines response of pts w pneumonia to treatment?

272
Q

diagnosis of occupational asthma?

A

Serial measurements of peak expiratory flow are recommended at work and away from work.

273
Q

Indications for steroid treatment in sarcoidosis?

A

patients with CXR stage 2 or 3 disease who have moderate to severe or progressive symptoms.

hypercalcaemia

eye, heart or neuro involvement

274
Q

what disease marker might have a role in monitoring disease activity of sarcoidosis?

A

ACE levels

275
Q

CXR of sarcoidosis may show different stages?

A

stage 0 = normal

stage 1 = bilateral hilar lymphadenopathy (BHL)

stage 2 = BHL + interstitial infiltrates

stage 3 = diffuse interstitial infiltrates only

stage 4 = diffuse fibrosis

276
Q

Respiratory features of Cystic fibrosis?

A

recurrent infections

cough, wheeze

bronchiectasis

pneumothorax

haemoptysis

resp failure, cor pulmonale

277
Q

GI features of cystic fibrosis?

A

Pancreatic insufficiency -> diabetes, steatorrhoea

meconium ileus in neonates

gallstones

cirrhosis

278
Q

diagnosis of cystic fibrosis?

A

sweat test > 60 mmol/L of NaCl

Faecal elastase decreased: exocrine pancreatic dysfunction

279
Q

Mx of resp features in cystic fibrosis?

A

postural drainage

bronchodilators

IV/PO abx for infective exacerbations/ prophylaxis

280
Q

Mx of GI features of Cystic fibrosis?

A

pancreatic enzyme replacement

fat soluble vitamin replacement therapy

ursodeoxycholic acid tx if impaired liver fn

281
Q

Which organisms cause chronic infection of lungs in Cystic fibrosis?

A

Pseudomonas aeruginosa (80%)

Burkholderia cepacia (3.5%)

282
Q

what drugs are assoc with pulmonary fibrosis w long term use?

A

Bleomycin

amiodraone

bulsulfan

methotrexate

sulfasalazine

nitrofurantoin

283
Q

Ix recommended in pts w suspected COPD?

A

post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio < 70%

CXR: hyperinflation, bullae, flat hemidiaphragm. + exclude lung cancer

FBC: exclude secondary polycythaemia

BMI calculation

284
Q

How to categorise COPD severity?

A

using FEV1

Stage 1 Mild:

Post bronchodilator FEV1/FVC: <70%

FEV1 >80% of predicted

Stage 2 -Moderate:

Post bronchodilator FEV1/FVC: <70%

FEV1 50-79% of predicted

Stage 3 - Severe:

Post bronchodilator FEV1/FVC: <70%

FEV1 30-49% of predicted

Stage 4 - Very severe:

Post bronchodilator FEV1/FVC: <70%

FEV1 <30% of predicted

285
Q

Tx of aspergillus infection?

A

Amphotericin B

286
Q

SEs of ethambutol?

A

optic neuritis

red green colour blindness

peripheral neuropathy

vertical nystagmus

287
Q

Diagnosis of ARDS involve which criteria?

A

all four of:

  1. Acute Onset
  2. bilat infiltrates present on CXR
  3. Pulm cap wedge pressure < 19mmHg or lack of clinical congestive HF
  4. refractory hypoxaemia with PaO2:FiO2<200
288
Q

most common organism causing infective exacerbations of COPD?

A
  1. haemophilus influenzae

2/3: strep pneumo, moraxella

289
Q

most common causes of bilateral hilar lymphadenopathy?

A

sarcoidosis and tuberculosis

290
Q

what NIV is used mainly for T2RF and what is mainly used for T1RF?

A

T2RF: BiPAP

T1RF: CPAP

291
Q

Features of Kartagener’s Syndrome?

A

aka primary ciliary dyskinesia (immotile cilia)

dextrocardia or complete situs inversus

bronchiectasis

recurrent sinusitis

subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)

292
Q

RFs for aspiration pneumonia?

A

Poor dental hygiene

Swallowing difficulties

Prolonged hospitalization or surgical procedures

Impaired consciousness

Impaired mucociliary clearance

293
Q

Mx of post op atelectasis?

A

Chest physiotherapy with mobilisation and breathing exercises

294
Q

most common organisms causing aspiration pneumonia?

A

Streptococcus pneumoniae

Staphylococcus aureus

Haemophilus influenzae

Pseudomonas aeruginosa

Medicine (16 decks)

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