Respiratory Flashcards
1
Q
Give three bacteria which can colonise the nares.
A
- Staphylococcus epidermidis
- Corynebacteria
- Staphylococcus aureus
2
Q
Give four potentially dangerous pathogens which can colonise the pharynx.
A
- Strep pneumoniae
- Haemophilus influenzae
- Strep pyogenes
- Neisseria
3
Q
Give four defences that the respiratory tract has against pathogens.
A
- Commensal flora
- Swallowing
- Mucociliary escalator
- Cough/sneeze reflex
4
Q
Give four conditions which may cause immune dysfunction of the lung.
A
- Primary immunodeficiency
- Complement deficiencies
- HIV
- Immunosuppressant therapy
5
Q
Give four reasons why someone’s ability to swallow may be impaired, putting them at a higher risk of respiratory infection.
A
- Stroke
- Motor neurone disease
- Tumour
- Surgery
6
Q
Give four intrinsic causes of altered lung physiology, putting the patient at increased risk of infection.
A
- Cystic fibrosis
- Bronchiectasis
- Emphysema
- Interstitial lung disease
7
Q
Give four extrinsic causes of altered lung physiology, putting the patient at increased risk of infection.
A
- Spinal disease
- Weakness
- Obesity
- Surgery
8
Q
What is the normal alveolar-arterial gradient?
A
<2kPa
9
Q
Give three causes of a raised Alveolar-arterial gradient.
A
- V/Q mismatch
- Diffusion limitation
- Right to left cardiac shunt
10
Q
Give two causes of a low PAO2.
A
- Hypoventilation
- Reduced FiO2 (or Patm)
11
Q
What physiological response occurs to alveolar hypoxia?
A
Pulmonary vasoconstriction
12
Q
In ambient hypoxia, what lung condition can result from widespread pulmonary vasoconstriction?
A
Pulmonary oedema
13
Q
Where does gas exchange begin in the respiratory system?
A
Respiratory bronchioles
14
Q
What breaks a breath hold?
A
Raised CO2 in the CSF (detected by central chemoreceptors)
15
Q
What do peripheral chemoreceptors usually respond to?
A
Large changes in PaO2.
16
Q
Give five functions of the lung.
A
- Gas exchange
- Acid-base balance
- Defence
- Hormones
- Heat exchange
17
Q
Give five ways that the lung provides defence against pathogens.
A
- Mucosal barrier
- Mast cells
- Macrophages
- Mucociliary clearance
- Cough reflex
18
Q
What is FEV1?
A
The forced expiratory volume in 1 second.
19
Q
Describe the FEV1 and FVC in obstructive lung disease.
A
FEV1 low
FVC normal
Low FEV1:FVC ratio
20
Q
Describe the FEV1 and FVC in restrictive airways disease.
A
Low FEV1
Low FVC
FEV1:FVC normal
21
Q
A disease of the airways typically causes a _____________ (obstructive/restrictive) disease.
A
Obstructive
22
Q
A disease of the lung parenchyma typically causes a _____________ (obstructive/restrictive) disease.
A
Restrictive
23
Q
A disease of the chest wall/pleura typically causes a _____________ (obstructive/restrictive) disease.
A
Restrictive
24
Q
What is TLCO?
A
Transfer factor (also known as diffusing capacity)
25
Give two causes of a low TLCO.
- Thickening of alveolar-capillary membrane
| - Reduced lung volumes
26
Give two causes of a raised TLCO.
- Increased capillary blood volume
| - Pulmonary haemorrhage
27
Give two causes of increased pulmonary capillary volume, which may lead to an increased TLCO.
- Polycythaemia
| - Left to right cardiac shunt
28
Is lung cancer more common in males or females?
Males
29
What proportion of all cancer deaths does lung cancer account for?
One third
30
What is the five year survival rate in lung cancer?
<5-10%
31
Give three general risk factors for lung cancer.
- Cigarettes
- Occupational
- Lung fibrosis
32
Give six occupational risk factors for lung cancer.
- Asbestos
- Radon
- Nickel
- Chromate
- Arsenic
- Uranium
33
What are the symptoms of lung cancer?
- Cough
- Recurrent chest infections
- Haemoptysis
- Increasing shortness of breath
- General malaise
- Weight loss
- Chest pain
- Hoarseness
- Loss of voice
34
Give four general signs of lung cancer.
- Cachexia
- Anaemia
- Clubbing
- Supraclavicular or axillary nodes
35
Give three potential chest signs that may appear in lung cancer.
- Consolidation
- Collapse
- Pleural effusion
36
What percentage of patients have paraneoplastic changes in lung cancer?
3-10%
37
Give nine paraneoplastic changes that may occur in lung cancer.
- Secretion of PTH
- SIADH
- Secretion of ACTH and other hormones
- Hypertrophic pulmonary osteo-arthropathy (HPOA)
- Myasthenic syndrome (Lambert-Eaton)
- Finger clubbing
- Migratory thrombophlebitis
- Non-infective endocarditis (Libman Sacks)
- DIC
38
Describe the stage of lung cancer on presentation.
Most present with late stage
39
Is primary or metastatic lung cancer more common?
Metastatic
40
What is the most common classification of lung cancer?
Carcinoma (90%)
41
Give six general types of lung tumour.
- Carcinoma
- Bronchial gland neoplasm
- Pleural neoplasia
- Soft tissue sarcoma/benign tumour
- Lymphoma
- Hamartoma
42
Briefly describe the pathology of how lung cancer develops.
- Precursor cell changes lead to dysplasia, which leads to cancer
43
Give three samples that can be collected in lung cancer.
- Sputum
- Bronchoalveolar lavage (BAL)
- Pleural fluid
44
Give six investigations to carry out in lung cancer.
- Fluid sample collection (cytology/histology)
- Biopsy
- Lobectomy/wedge/pneumonectomy
- CXR
- Bronchoscopy
- Lung function tests
45
Give five types of primary lung carcinoma.
- Squamous cell carcinoma
- Adenocarcinoma (bronchioloalveolar adenocarcinoma)
- Large (non-small) cell undifferentiated carcinoma
- Small cell carcinoma
- Carcinoid tumour
46
Primary lung carcinomas can be broadly divided into what two groups?
- Small cell lung carcinoma (SCLC)
| - Non-small cell lung carcinoma (NSCLC)
47
What grade is a small cell lung carcinoma?
High grade
48
What is the major risk factor for small cell lung carcinoma?
Cigarette smoking
49
What stage is the cancer usually at on presentation in small cell lung carcinoma?
Has usually spread by presentation
50
What is the standard treatment for small cell lung carcinoma?
Chemotherapy
51
What grade are non-small cell lung carcinomas usually?
Variable grade
52
What is a major risk factor for non-small cell lung carcinomas?
Cigarette smoking
53
Describe the stage at presentation of non-small cell lung carcinoma.
May have metastasised
54
Compare the rate of growth of small cell and non-small cell lung carcinomas.
Small cell carcinomas are faster
55
What is the usual treatment for non-small cell lung carcinomas?
Chemotherapy may be offered, but surgery and radiotherapy are the mainstay of treatment.
Can also use new drugs blocking specific tumour cell receptors.
56
What age group do carcinoid tumours of the lung more commonly occur in?
Younger people
57
Is smoking a major risk factor for carcinoid lung tumours?
No
58
Describe the prognosis for carcinoid lung tumours.
All are malignant, but they are less aggressive.
59
Give two types of lung lymphoma.
- Hodgkin’s lymphoma
| - Non-Hodgkin’s lymphoma/BALTOMA
60
What is a BALTOMA?
Bronchus associated lymphoid tissue lymphoma
61
Give an example of a sarcoma which occurs in the lung.
Epitheloid haemangio-endothelioma
62
What does PL1/PL2 indicate when staging lung tumours?
Pleural involvement
63
What does M0 mean when staging lung tumours?
No metastases
64
What does M1a mean when staging lung tumours?
Contralateral lung, or pleural/pericardial effusion/nodule
65
What does M1b mean when staging lung tumours?
Distant spread outside chest
66
Give three examples of non-malignant lung nodules.
- TB and other infections
- Lymph nodes
- Benign neoplasia (eg. Hamartoma)
67
What is a hamartoma?
Disorganised benign tumour of various tissue types.
68
Give three types of pleural neoplasia.
- Metastatic disease
- Pleural fibroma
- Malignant mesothelioma
69
Describe a pleural fibroma.
- Solitary fibrous tumour
| - Most are benign
70
What patient demographic are malignant mesotheliomas more common in?
Males >60yrs
71
What is a major risk factor for malignant mesothelioma?
Asbestos exposure
72
What is the average survival time in a malignant mesothelioma?
8-12months
73
Describe the treatment for malignant mesothelioma.
Limited benefit from surgery, chemotherapy, radiotherapy
74
Describe the microscopic appearance of a malignant mesothelioma.
Many different microscopic appearances
75
Give six consequences of asbestos exposure.
- Plaques
- Persistent pleural effusion
- Pleural fibrosis
- Lung cancer
- Asbestosis (diffuse interstitial fibrosis)
- Mesothelioma
76
Give ten differential diagnoses of a lung nodule.
- Primary or metastatic malignancy
- Abscesses
- Granuloma
- Carcinoid tumour
- Pulmonary hamartoma
- Arterio-venous malformation
- Encysted effusion (fluid, blood, pus)
- Cyst
- Foreign body
- Skin tumour
77
What are ‘interstitial lung diseases’?
A general term for diseases resulting in an increased amount of connective tissue between the alveolar spaces in the lungs.
78
In lung fibrosis, do patients have trouble breathing in or out?
In
79
Are interstitial lung diseases generally obstructive or restrictive?
Restrictive
80
Give three general consequences of interstitial lung diseases.
- Increased stiffness
- Decreased compliance
- Loss of alveolar surface
81
Describe the Tco expected in interstitial lung diseases.
Reduced
82
Describe the VC expected in interstitial lung diseases.
Reduced
83
Describe the FEV1 expected in interstitial lung diseases.
Reduced
84
Describe the FEV1/FVC ratio expected in interstitial lung diseases.
Normal
85
Describe the peak expiratory flow rate expected in interstitial lung diseases.
Normal
86
Give four general clinical features of interstitial lung diseases.
- Dyspnoea on exertion
- Non-productive paroxysmal cough
- Abnormal breath sounds
- Abnormal CXR
87
Give five examples of acute interstitial lung diseases.
- Adult respiratory distress syndrome
- Drug and toxin reactions
- Gastric aspiration
- Radiation pneumonitis
- Diffuse intrapulmonary haemorrhage
88
Give five causes of adult respiratory distress syndrome.
- Shock
- Trauma (direct pulmonary or multisystem)
- Infections
- Gas inhalation
- Narcotic abuse
89
Briefly describe the pathology in adult respiratory distress syndrome.
- Polymorphs release enzymes and activate complement
- Increased capillary permeability leads to pulmonary oedema
- Diffuse alveolar damage with hyaline membranes
90
What is the fatality rate in adult respiratory distress syndrome?
50%
91
What are the clinical features of adult respiratory distress syndrome?
- Cyanosis
- Tachypnoea
- Dyspnoea
- Tachycardia
- Pulmonary oedema
- Arterial hypoxaemia
- Peripheral vasodilation
92
What would a CXR show in adult respiratory distress syndrome?
Bilateral pulmonary infiltrates
93
Give two cytotoxic drugs that can cause an acute interstitial lung disease.
- Busulphan
| - Bleomycin
94
How does paraquat (a potent herbicide) cause an acute interstitial lung disease?
- Releases hydrogen peroxide and superoxide free radical
| - Remains in high concentrations in the lungs after ingestion
95
Give two potential consequences of radiation pneumonitis.
- Respiratory distress syndrome
| - Progressive pulmonary fibrosis
96
Give five examples of chronic interstitial lung diseases.
- Fibrosing alveolitis
- Pneumoconioses
- Sarciodosis
- Diffuse malignancies
- Rheumatoid diseases
97
What is another name for fibrosing alveolitis?
Idiopathic pulmonary fibrosis
98
Give two pathological processes that occur in idiopathic pulmonary fibrosis.
- Inflammatory cell infiltrate
| - Pulmonary fibrosis
99
Describe the macroscopic appearance of the lungs in idiopathic pulmonary fibrosis.
- Abnormally large irregular spaces separated by thick fibrous septa
- End stage fibrosis = honeycomb lung
100
Which areas of the lung are predominantly affected by idiopathic pulmonary fibrosis?
Subpleural regions
101
What pattern will the pulmonary function tests show in idiopathic pulmonary fibrosis?
Restrictive
102
Give the symptoms of idiopathic pulmonary fibrosis.
- Dry cough
- Exertional dyspnoea
- Malaise
- Weight loss
- Arthralgia
103
Give three signs of idiopathic pulmonary fibrosis.
- Cyanosis
- Finger clubbing
- Fine end-inspiratory crepitations
104
What would be ABG show in idiopathic pulmonary fibrosis?
Low PaO2
105
What would be CRP be in idiopathic pulmonary fibrosis?
High
106
What would the immunoglobulin levels be in idiopathic pulmonary fibrosis?
High
107
What would the CXR show in idiopathic pulmonary fibrosis?
- Reduced lung volume
| - Honeycomb lung
108
Give three potential complications in idiopathic pulmonary fibrosis.
- Cor pulmonale
- Respiratory failure
- Increased risk of lung cancer
109
What is the 5 year survival rate in idiopathic pulmonary fibrosis?
50%
110
What is pneumoconiosis?
Lung disease caused by inhaled dust (can be organic or inorganic).
111
Give four different types of reaction that can occur in pneumoconiosis.
- Inert
- Fibrous
- Allergic
- Neoplastic
112
Give an example of an inert reaction to pneumoconiosis.
Coal worker’s pneumoconiosis
113
Give three examples of fibrous reactions to pneumoconiosis.
- Progressive massive fibrosis
- Asbestosis
- Silicosis
114
Give an example of an allergic reaction to pneumoconiosis.
Extrinsic allergic alveolitis
115
Give two examples of neoplastic reactions to pneumoconiosis.
- Mesothelioma
| - Lung cancer
116
Describe the pathology in coal worker’s pneumoconiosis.
- Coal ingested by alveolar macrophages (dust cells)
| - Macrophages aggregate around bronchioles
117
What is anthracosis?
Presence of coal dust pigment in the lung
118
Describe macular coal worker’s pneumoconiosis.
Aggregates of dust laden macrophages with no significant scarring.
119
Describe nodular coal worker’s pneumoconiosis.
Nodules >10mm in a background of extensive macular CWP, with no significant scarring.
120
Give three consequences that can result from coal worker’s pneumoconiosis.
- Progressive massive fibrosis
- Emphysema
- Honeycomb lung and/or cor pulmonale
121
Where are silicates found?
Stone and sand
122
Briefly describe the pathology of silicosis.
- Silicates are toxic to macrophages
- Macrophages die and release proteolytic enzymes
- This leads to tissue destruction and fibrosis
- Nodules formed after many years of exposure
123
Give a disease that has a higher incidence in people with silicosis.
TB
124
What is asbestos?
An inconsumable silicate
125
What type of hypersensitivity reaction is extrinsic allergic alveolitis?
Type 3
126
Describe the basic pathology in extrinsic allergic alveolitis.
- Hypersensitivity leads to bronchiolitis
| - Later leads to chronic inflammation and granulomas
127
Give the possible outcomes of extrinsic allergic alveolitis.
- Resolution
| - Fibrosis
128
What is sarcoidosis?
Deposits of immune complexes resulting in a granulomatous disease mainly affecting the lungs and lymph nodes.
129
What type of hypersensitivity reaction is sarcoidosis?
Type IV
130
Give four symptoms of sarcoidosis.
- Dry cough
- Progressive dyspnoea
- Decreased exercise tolerance
- Chest pain
131
Describe Kveim test.
- Subcutaneous injection of sterile homogenised sarcoid tissue
- Induces granulomas in patients with sarcoidosis
132
What investigation should be used to assess sarcoidosis?
CXR
133
Give a potential treatment for sarcoidosis?
Corticosteroids
134
Give three potential affects of Rheumatoid disease on the lungs.
- Diffuse fibrosis
- Rheumatoid nodules
- Caplan’s syndrome
135
What is Caplan’s syndrome?
Rheumatoid arthritis + pneumoconiosis
136
What will the pleura show in rheumatoid disease affecting the lungs?
Fibrosis and lymphocytic aggregates
137
Give two diffuse malignancies that may cause a chronic interstitial lung disease.
- Lymphangitis
| - Bronchioloalveolar carcinoma
138
Describe lymphangitis and how it affects the lungs.
Tumour spreads through lung and obstructs lymphatics
139
How does brochioloalveolar carcinoma cause an interstitial lung disease?
Spreads on the surface of the lung to cause local scarring.
140
Is asthma an obstructive or restrictive disease?
Obstructive
141
Give seven pathological mechanisms that occur in asthma.
- Increased irritability of the bronchi causing spasm
- Bronchial obstruction with distal overinflation or atelectasis (lung collapse)
- Overdistended lungs
- Enlarged bronchial mucous glands with excess secretions (mucous plugs in bronchi)
- Bronchial inflammation
- Bronchial wall smooth muscle hypertrophy
- Thickening of bronchial basement membrane
142
Give three types of extrinsic asthma.
- Atopic
- Occupational
- Allergic bronchopulmonary aspergillosis
143
Briefly describe the pathology in extrinsic asthma.
Environmental agents lead to IgE cross linking and mast cell degranulation.
144
What type of reaction occurs in extrinsic asthma?
IgE/type 1 hypersensitivity
145
What type of reaction occurs in occupational asthma?
Type 3 hypersensitivity
146
Give seven causes of intrinsic asthma.
- Aspirin
- Cold
- Infection
- Stress
- Exercise
- SO2
- Pollutants
147
Give two other conditions which are associated with intrinsic asthma.
- Recurrent chest infections
| - Chronic bronchitis
148
Give three other things associated with aspirin-induced asthma.
- Recurrent rhinitis
- Nasal polyps
- Skin urticaria
149
What organism causes allergic bronchopulmonary aspergillosis?
Aspergillus fumigatus
150
What type of reaction occurs in allergic bronchopulmonary aspergillosis?
Type I and type III hypersensitivity reaction
151
Give the two categories that eosinophilic asthma can be divided into.
- Atopic
| - Non-atopic
152
Give three causes of atopic asthma.
- Fungal allergy
- Common aeroallergens
- Occupation/pets/exposures
153
Give three types of non-eosinophilic asthma.
- Non-smoking, non-eosinophilic
- Smoking-associated
- Obesity-related
154
What are the symptoms of asthma?
- Cough
- Shortness of breath
- Episodic wheezing
- Chest tightness
- Secretions
155
Give two hallmark clinical features of asthma.
- Diurnal variation
| - Reversibility
156
Is asthma typically worse in the morning or evening?
Morning
157
What is type 1 brittle asthma?
Chronic severe (bad all the time)
158
What is type 2 brittle asthma?
Sudden dips
159
Give three features of the wheeze commonly heard in asthma.
- Polyphonic
- Expiratory
- Widespread
160
Give two features you WOULDN’T expect to find on a clinical examination in a patient with asthma.
- Crackles
| - Sputum
161
Give six factors with may provoke asthma.
- Allergens
- Infections
- Menstrual cycle
- Exercise
- Cold air
- Laughter/emotion
162
Give three simple tests to carry out in asthma.
- Blood count (eosinophils)
- Tests for atopy and allergy (Skin prick and IgE)
- CXR
163
Give four findings on pulmonary function tests in asthma.
- Airways obstruction
- Reduced FEV1
- Reduced FEV1/FVC ratio
- Reduction in PEFR (diurnal variation)
164
How can challenge agents be used to assess asthma?
There is increased responsiveness to challenge agents (eg. Mannitol, methacholine)
165
How can reversibility testing help to diagnose asthma?
- 12% increase in FEV1 (with increase in 200ml in volume) after bronchodilator is positive
- 400ml+ increase makes asthma highly likely
166
How can an exhaled NO test be used to assess asthma?
- NO given off by inflamed lungs
- Marker of eosinophilic inflammation
- This is non-specific
167
Give a factor that may suppress NO production by the lungs in asthma.
Smoking
168
Give two factors that may increase NO production by the lungs in asthma.
- Viral infections
| - Rhinitis
169
What two factors should be considered when assessing the severity and control of asthma?
- Day to day control
| - Exacerbation
170
What three criteria, named RCP3, are used to assess day to day control of asthma?
- Recent nocturnal waking?
- Usual asthma symptoms in day?
- Interference with ADLs?
171
What four things are taken into account when assessing the severity of asthma using exacerbations?
- A and E attendances
- GP
- Admissions
- ITU
172
What are the three elements of Samter’s triad?
- Bronchial asthma
- Nasal polyps
- Aspirin intolerance
173
Compare the age of onset in asthma and COPD.
ASTHMA
- Usually earlier onset
COPD
- Usually onset later in life
174
Compare the association with smoking in asthma and COPD.
ASTHMA
- Not associated with smoking
COPD
- Usually seen in smokers
175
Compare the disease progression in asthma and COPD.
ASTHMA
- Relatively stable disease
COPD
- Progressive and worsens over time
176
Compare the diurnal variation in asthma and COPD.
ASTHMA
- Diurnal variation
COPD
- Less diurnal variation
177
Compare the day-to-day variation in asthma and COPD.
ASTHMA
- Day to day variation
COPD
- Less day to day variation
178
Compare the seasonal changes in asthma and COPD.
ASTHMA
- Not really seasonal
COPD
- Worse in winter
179
Compare the sputum production in asthma and COPD.
ASTHMA
- Less sputum production
COPD
- Sputum production
180
What is ACOS?
Asthma COPD overlap syndrome
181
Give five risk factors for asthma death.
- >3 classes of treatment
- Recent admission/frequent attender
- Previous near-fatal disease
- Brittle disease
- Psychosocial factors
182
Give four general methods of treating asthma.
- Avoidance of triggers
- Bronchodilators
- Anti-inflammatory drugs
- New biological drugs
183
How do bronchodilators work to treat asthma?
Relieve symptoms
184
How do anti-inflammatory drugs work to treat asthma?
Prevent exacerbations
185
Give four categories of bronchodilators which are used in asthma.
- Beta agonists
- Leukotriene receptor antagonists
- Theophyllines
- Long acting beta agonists
- Anticholinergics
186
Give a beta agonist used to treat asthma.
Salbutamol
187
Give two leukotriene receptor antagonists used to treat asthma.
- Montelukast
| - Zafirlukast
188
Give a theophylline used to treat asthma.
Aminophylline
189
Give two long acting beta agonists used to treat asthma.
- Salmeterol
| - Formoterol
190
Give two anticholinergics used to treat asthma.
- Ipratropium
| - Tiotropium
191
What class of anti-inflammatory drugs are used to treat asthma?
Steroids
192
Give an example of a steroid used to treat asthma.
Beclometasone
193
Give two examples (and how they work) of new biological drugs used to treat asthma.
- Omalizumab (Anti-IgE)
| - Mepolizumab (Anti-IL5)
194
Give the three first steps (in order) in managing acute asthma.
- High flow oxygen
- Emergency beta agonists (nebuliser)
- Brief history/examination
195
Describe the PEFR, RR, pulse, and speech in moderate acute asthma.
- PEFR = >50%
- RR <25
- Pulse <110
- Normal speech
196
Describe the PEFR, RR, pulse, and speech in severe acute asthma.
How many criteria need to be present?
- PEFR 33%-50%
- RR >25
- Pulse >110
- Inability to complete sentences
*Only one has to be present
197
Describe the PEFR, O2 sats/PaO2, and PaCO2 in life-threatening acute asthma.
- PEFR <33%
- O2 <92%
- PaO2 <8kPa
- Normal PaCO2
198
What would you expect the PaCO2 to be in acute asthma?
Low due to hyperventilation.
*If normal or high this is a bad sign
199
Give seven indications, other than vital signs, of life-threatening acute asthma.
- Altered consciousness level
- Exhaustion
- Arrhythmia
- Hypotension
- Silent chest
- Poor effort
- Cyanosis
200
Give two organs that are affected in Goodpasture’s syndrome.
- Lungs
| - Kidney
201
What is the clinical presentation of Goodpasture’s syndrome in the kidney?
Acute glomerulonephritis
202
Give two effects of Goodpasture’s syndrome on the lung?
- Haemoptysis
| - Diffuse pulmonary haemorrhage
203
What would be seen on a CXR in Goodpasture’s syndrome?
Infiltrates due to pulmonary haemorrhage (often in lower zones)
204
What would be seen on a kidney biopsy in Goodpasture’s syndrome?
Crescentic glomerulonephritis
205
How is Goodpasture’s syndrome treated?
- Vigorous immunosuppression
| - Plasmapheresis
206
What is the cut off for pulmonary hypertension at rest?
>25mmHg
207
What is the cut off for pulmonary hypertension during exercise?
>30mmHg
208
Describe primary pulmonary hypertension.
Rare, occurs in the absence of chronic lung or heart disease.
209
Describe secondary pulmonary hypertension.
Quite common, develops as a complication of lung or heart disease.
210
Give five causes of primary pulmonary hypertension.
- Idiopathic
- Drugs
- HIV
- Collagen vascular disease
- Congenital systemic-to-pulmonary shunts
211
Give four common causes of secondary pulmonary hypertension.
- COPD
- Interstitial lung disease
- Left ventricular failure
- Chronic pulmonary thromboemboli
212
Describe the clinical presentation of primary pulmonary hypertension.
- Exertional dyspnoea
- Fatigue
- Dizziness
- Syncope
213
Describe the clinical presentation of secondary pulmonary hypertension.
- Worsening of symptoms of pre-existing condition
| - Increasing breathlessness
214
What is the five year survival rate in primary pulmonary hypertension?
25-50%
215
Describe the prognosis in secondary pulmonary hypertension.
Generally implies significant underlying cardiac or lung disease with poor prognosis.
216
Give two investigations to carry out in pulmonary hypertension.
- Echocardiogram
| - Right heart catheterisation
217
What is cystic fibrosis?
An inherited disorder caused by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene.
218
Describe the inheritance pattern in cystic fibrosis.
Autosomal recessive
219
What is allelic heterogeneity, in terms of cystic fibrosis?
Many different mutations in the same gene can cause the disease.
220
What does the CFTR gene code for?
A chloride channel
221
Describe the pathology of cystic fibrosis.
Lack of normal CFTR causes defective electrolyte transfer across epithelial cell membranes, resulting in thick mucous secretions.
222
What is the most common form of presentation of cystic fibrosis?
Pulmonary disease
223
At what stage in cystic fibrosis does liver disease develop?
Late
224
Describe a neonatal presentation of cystic fibrosis.
- Failure to thrive
- Meconium ileus (bowel obstruction)
- Rectal prolapse
225
Describe how a child/young adult might present with cystic fibrosis.
- Cough
- Wheeze
- Recurrent infections
- Bronchiectasis
- Pneumothorax
- Haemoptysis
- Respiratory failure
- Cor pulmonale
- Pancreatic insufficiency
- Distal intestinal obstruction syndrome
- Gallstones
- Cirrhosis
- Male infertility
- Osteoporosis
- Arthritis
- Vasculitis
- Nasal polyps
- Sinusitis
- Hypertrophic pulmonary osteoarthropathy (HPOA)
226
Give three signs of cystic fibrosis.
- Cyanosis
- Finger clubbing
- Bilateral course crackles
227
What organisms commonly cause respiratory infections in cystic fibrosis patients?
- Initially, infection is caused by common bacteria which colonise the lungs
- Eventually Pseudomonas aeruginosa becomes the dominant organism
228
Give two macroscopic changes that may occur in cystic fibrosis.
- Widespread bronchiectasis
| - Liver may be fatty/cirrhotic
229
Give four microscopic changes that may be seen in cystic fibrosis.
- Lungs contain thick mucous
- Acute inflammation may be seen if there is active infection in the lungs
- Periportal fibrosis in liver, may lead to cirrhosis
- Thickened bile in intrahepatic bile ducts
230
Give three diagnostic tests for cystic fibrosis.
- Sweat test
- Genetics
- Faecal elastase
231
What sweat test results would suggest cystic fibrosis?
- Sodium and chloride >60mmol/L
| - Chloride usually greater than sodium
232
How can the faecal elastase test be used to assess cystic fibrosis?
Screening test for exocrine pancreatic dysfunction (low measurement suggests insufficiency)
233
What blood tests would it be useful to carry out in cystic fibrosis?
- FBC
- U and E
- LFT
- Clotting
- Vitamins A/D/E
234
How could the presence of an infection be detected in cystic fibrosis?
Cough swab or sputum culture
235
How can diabetes be picked up in cystic fibrosis patients?
Annual glucose tolerance test
236
Give two potential features of a CXR in cystic fibrosis.
- Hyperinflation
| - Bronchiectasis
237
Give three potential USS findings in cystic fibrosis.
- Fatty liver
- Cirrhosis
- Chronic pancreatitis
238
What pattern might the spirometry results show in cystic fibrosis?
Obstructive
239
As well as faecal elastase, what other faecal test might be useful in cystic fibrosis?
Faecal fat analysis
240
Give four management principles for the chest in cystic fibrosis.
- Physiotherapy
- Antibiotics for acute infections and prophylactically
- Mucolytics
- Bronchodilators
241
Give four management principles for the GI system in cystic fibrosis.
- Pancreatic enzyme replacement
- Fat soluble vitamin supplements (A, D, E, K)
- Ursodeoxycholic acid for impaired liver function
- Cirrhosis may require liver transplant
242
Give four management principles for advanced lung disease in cystic fibrosis.
- Oxygen
- Diuretics (for Cor pulmonale)
- Non-invasive ventilation
- Lung or heart/lung transplant
243
What is the average life expectancy for a patient with cystic fibrosis?
35yrs
244
What is the most common cause of death in cystic fibrosis?
Pulmonary disease
245
What is a pleural effusion?
An accumulation of excess fluid within the pleural space.
246
What is the protein content of a transudate pleural effusion?
<25g/L
247
What is the protein content of an exudate pleural effusion?
>35g/L
248
What is a haemothorax?
Blood in the pleural space
249
What is an empyema?
Pus in the pleural space
250
What is a chylothorax?
Chyle (lymph with fat) in the pleural space
251
What is the term for blood and air in the pleural space?
Haemopneumothorax
252
Give four general causes/mechanisms of transudate pleural effusion.
- Increased venous pressure
- Hypoproteinaemia
- Hypothyroidism
- Meigs’ syndrome
253
Give three causes of transudate pleural effusion due to increased venous pressure.
- Left ventricular failure
- Constrictive pericarditis
- Fluid overload
254
Give three causes of transudate pleural effusion due to hypoproteinaemia.
- Cirrhosis
- Nephrotic syndrome
- Malabsorption
255
Describe the mechanism which causes an exudate pleural effusion.
Increased leakiness of pleural capillaries.
256
Give six causes of exudate pleural effusion.
- Pneumonia
- TB
- Pulmonary infarction
- Pulmonary embolism
- Malignancy
- Multisystem autoimmune diseases (SLE, RA)
257
What are the symptoms of a small pulmonary effusion.
May be asymptomatic
258
Give two symptoms of a large pleural effusion.
- Breathlessness
| - Pleuritic chest pain
259
Give seven signs of a pleural effusion.
- Decreased expansion
- Stony dull percussion note
- Diminished breath sounds
- Decreased vocal resonance
- Bronchial breathing above effusion
- Tracheal deviation (away from effusion) if large effusion
- Signs of underlying disease
260
Give three signs of a pleural effusion that may be seen on a CXR.
- Blunting of costophrenic angles
- Water-dense shadows with concave upper borders
- Completely flat horizontal upper borders implies that there is also a pneumothorax
261
When is an ultrasound useful in pleural effusion?
To identify presence of pleural fluid and to guide aspiration.
262
Give four tests that can be carried out on a diagnostic pleural aspiration.
- Clinical chemistry
- Bacteriology
- Cytology
- Immunology
263
Give four management options for a pleural effusion.
- Treat underlying cause
- Drainage
- Pleurodesis
- Surgery
264
When is drainage of a pleural effusion carried out?
- If symptomatic
| - Not in TB
265
How fast should the fluid be removed when draining a pleural effusion?
Slowly
266
What is pleurodesis?
Adhesion of the pleural layers (obliterating the pleural space).
267
Give three substances that can be used for Pleurodesis.
- Tetracycline
- Bleomycin
- Talc
268
What is the prognosis for a parapeumonic/pulmonary embolus effusion?
Usually resolve upon treatment
269
What is the prognosis for a pleural effusion due to left ventricular failure?
Usually implies advanced disease and poor prognosis.
270
Describe the prognosis in a pleural effusion due to malignancy.
Due to metastatic disease so has very poor prognosis.
271
Give two causes of a turbid, yellow pleural effusion.
- Empyema
| - Parapneumonic effusion
272
Give three causes of a haemorrhagic pleural effusion.
- Trauma
- Malignancy
- Pulmonary infarction
273
Give two causes of a pleural effusion with increased neutrophils.
- Parapneumonic effusion
| - Pulmonary embolism
274
Give five causes of a pleural effusion with increased lymphocytes.
- Malignancy
- TB
- Rheumatoid arthritis
- Lupus
- Sarcoidosis
275
Give a cause of pleural effusion with many mesothelial cells.
Pulmonary infarction
276
Give a cause of a pleural effusion containing abnormal mesothelial cells.
Mesothelioma
277
Give a cause of a pleural effusion containing multinucleated giant cells.
Rheumatoid arthritis
278
Give a cause of pleural effusion which contains lupus erythematosus cells.
Lupus
279
Give five causes of a pleural effusion with glucose <3.3mmol/L.
- Empyema
- Malignancy
- TB
- Rheumatoid arthritis
- SLE
280
Give five causes of a pleural effusion with pH <7.2.
- Empyema
- Malignancy
- TB
- Rheumatoid arthritis
- SLE
281
Give five causes of a pleural effusion with raised LDH.
- Empyema
- Malignancy
- TB
- Rheumatoid arthritis
- SLE
282
Give four causes of a pleural effusion with raised amylase.
- Pancreatitis
- Carcinoma
- Bacterial pneumonia
- Oesophageal rupture
283
Give four causes of a pleural effusion with low complement levels.
- Rheumatoid arthritis
- SLE
- Malignancy
- Infection
284
Give two pulmonary diseases in which Pseudomonas aeruginosa is a likely cause of infection.
- Cystic fibrosis
| - Bronchiectasis
285
What is the term for when Streptococcus pneumoniae gets into the blood?
Invasive pneumococcal pneumona
286
Describe the shape of Haemophilus.
Coccobacilli (short rod)
287
What are the X, V, and XV disks sometimes used on agar plates?
Growth factors - can see which ones the organism needs to grow.
288
Give an alternative stain to the Zeil Neelsen stain that can be used to identify Mycobacteria.
Auramine-phenol stain
289
Give two cultures on which Mycobacteria can be cultured.
- Lowenstein Jensen slope
| - Mycobacterial growth indicator tube (MGIT)
290
Give two ways that a sputum sample can be obtained from a patient with a non-productive cough.
- Bronchoalveolar lavage
| - Induced sputum sample (physiotherapy + nebuliser)
291
Give two organisms that cause tuberculosis.
- Mycobacterium tuberculosis
| - Mycobacterium bovis
292
Give a stain that can identify Mycobacteria.
Ziehl-Neelsen stain
293
Give another name for Mycobacteria.
Acid fast bacilli
294
What is the most common infectious disease worldwide?
TB
295
Where in the world is TB more prevalent?
Africa and third world countries
296
Give three groups of people who have higher rates of TB in the UK.
- Black African
- Indian
- Pakistani
297
Give six risk factors for tuberculosis.
- Born in high prevalence area
- IV drug users
- Homeless
- Alcoholic
- Prisons
- HIV
298
How is TB spread?
Aerosol spread
| Spitting/sneezing
299
What does ‘smear positive’ mean in relation to TB?
Bacteria can be identified in the sputum.
300
If a patient is smear positive for TB, what are the chances that household contacts will also be infected?
27-50%
301
What type of TB is caused by Mycobacterium bovis?
Bovine TB
302
How can bovine TB be caught, and who is at increased risk?
- Caught from unpasteurised milk
| - Butchers/abattoir workers are at increased risk
303
Once Mycobacterium tuberculosis has entered a person, what is the most common consequence?
Person mounts an effective immune response that encapsulates and contains the organism forever.
304
What percentage of people infected with Mycobacterium tuberculosis develop clinically evident primary pulmonary disease?
2-5%
305
What is the disease called when latent TB reactives at a later date?
Post primary disease
306
Give five risk factors for developing active TB once infected.
- Elderly
- Malnourished
- Diabetic
- Immunosuppressed
- Alcoholic
307
Which area of the lung do the bacteria settle in in TB and why?
Lung apex, because there is more air and less blood supply/immune cells.
308
What forms when Mycobacteria tuberculosis settle in the lung apex?
Caseating granuloma
309
Describe the pathology of primary pulmonary TB.
- Bacilli and macrophages coalesce in apex of lung to form caseating granuloma
- Bacilli taken in lymphatics to lymph nodes
- As granuloma grows middle becomes necrotic and full of pus, and a cavity is produced
- Cavity full of TB bacilli, which are expelled when the patient coughs
310
What is the caseating granuloma called in primary pulmonary TB?
Primary (Ghon) focus
311
What is the primary focus (the caseating granuloma) + involvement of the mediastinal lymph nodes called in primary pulmonary TB?
Primary (Ghon) complex
312
Give the systemic features of TB.
- Weight loss
- Low grade fever
- Anorexia
- Night sweats
- Malaise
313
Give four symptoms of pulmonary TB.
- Cough >3weeks
- Chest pain
- Breathlessness
- Haemoptysis
314
Give four pathological consequences of TB.
- Consolidation
- Collapse
- Pleural effusion
- Pericardial effusion
315
How does a pleural effusion occur in TB?
Rupture of the primary focus into the pleural space.
316
How is a pleural effusion treated in TB?
Does not need draining
317
How does a pericardial effusion occur in TB?
Rupture of a lymph node through the pericardium.
318
Give seven types of non-pulmonary TB.
- Miliary TB
- Pleural TB
- Lymph node TB
- Bone and joint TB
- Abdominal TB
- Genitourinary TB
- CNS TB
319
Describe miliary TB.
Disseminated infection, forming many small granulomas.
320
What is the second most common form of TB, after pulmonary?
Lymph node TB
321
Give two presentations of bone and joint TB.
- Pain/swelling of joint
| - Potts disease in spinal cord
322
Give three features of abdominal TB.
- Ascites
- Abdominal lymph nodes
- Ileal malabsorption
323
Give four features of genitourinary TB.
- Epididymitis
- Frequency
- Dysuria
- Haematuria
324
Give three features of CNS TB.
- Meningitis
- CN palsy
- Tuberculoma
325
Give seven potential non-specific findings in tests that may show up in TB.
- Normochromic normocytic anaemia
- Thrombocytosis
- Raised ESR/CRP
- Hypoalbuminaemia
- Hypergammaglobulinaemia
- Hypercalcaemia
- Sterile pyuria
326
Give three techniques/tests that can definitively diagnose TB.
- Microscopy
- PCR
- Culture
327
Give five samples that can be taken which can help to diagnose TB.
- Sputum
- Urine
- CSF
- Pleural fluid
- Biopsy (lymph nodes, peritoneum, bone, brain, etc)
328
How many sputum samples must be taken to diagnose TB?
3
329
Give two possible methods of diagnosing latent TB.
- Tuberculin skin test ‘mantoux’
| - Interferon gamma release assays (IGRAs)
330
Briefly describe the tuberculin skin test.
- Protein derived from organism injected intradermally
- Stimulates type 4 hypersensitivity reaction
- Positivity determined by size of reaction that is produced
*Measures immune response, not actual bacteria
331
Give two cases where a false negative tuberculin skin test would be produced.
- Immunosuppressed
| - Miliary TB
332
Give an example of when a false positive tuberculin skin test would be produced.
BCG vaccine
333
Briefly describe the interferon gamma release assay to test for latent TB.
- Take patient’s blood and mix with antigen specific to M.tuberculosis
- Measure IFN-y released by cells in patient’s blood
334
Give a major differential diagnosis for TB.
Cancer
335
What is the general principle of the treatment of active TB?
Treat with at least 4 drugs for at least 6 months.
336
What four drugs are used to treat TB?
- Rifampicin
- Isoniazid
- Pyrazinamide
- Ethambutol
337
How long is Rifampicin given in TB?
6 months (12 months if CNS)
338
Describe the mechanism of action of Rifampicin.
Blocks protein synthesis
339
Give three side effects of Rifampicin.
- Red urine
- Hepatitis
- Drug interactions (oral contraceptive)
340
How long is Isoniazid given for in active TB?
6 months (12 months if CNS)
341
Describe the mechanism of action of Isoniazid.
Blocks cell wall synthesis
342
Give two side effects of Isoniazid.
- Hepatitis
| - Neuropathy
343
How long is pyrazinamide given for in active TB?
First 2 months of treatment
344
Describe the mechanism of action of pyrazinamide.
Bacteriocidal initially, less effective later
345
Give three side effects of pyrazinamide.
- Hepatitis
- Arthralgia/gout
- Rash
346
How long is Ethambutol given for in active TB?
First 2 months
347
Describe the mechanism of action of Ethambutol.
Blocks cell wall synthesis
348
Give a side effect of Ethambutol.
Optic neuritis
349
Why is treatment given for so long in TB?
Treatment allows early killing of active bacteria, and when dormant bacteria reactivate months down the line there is opportunity for those to be killed too.
350
Which is the drug which is most common for single-agent resistance TB in the UK?
Isoniazid
351
Which two drugs are responsible for most cases of multi-drug resistant TB?
Rifampicin and Isoniazid
352
Give four risk factors for having multi-drug resistant TB.
- Previous treatment
- High risk area
- Contact of resistant TB
- Poor response to therapy
353
Give five consequences of drug resistant TB.
- More difficult to treat
- Side effects
- IV/IM treatment
- >20months treatment
- Increased relapse rate
354
Give four groups of people at risk of latent TB.
- Contacts
- New entrants
- Health care workers
- Immunocompromised
355
What is the treatment for latent TB?
6 months Isoniazid
OR
3 months Rifampicin + Isoniazid
356
Give three prevention strategies for TB.
- Active case finding
- Detection and treatment of latent TB
- Vaccination
357
Who routinely gets a vaccination against TB?
Neonates in high risk groups
358
What vaccine is used for TB?
BCG
359
Define ‘pneumonia’.
Inflammation of the lung parenchyma
360
Give 11 organisms which can cause community-acquired pneumonia.
Which is most common?
- Streptococcus pneumoniae (most common)
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Chlamydophila psittaci
- Haemophilus influenzae
- Legionella pneumophilia
- Coxiella burnetti
- Staphylococcus aureus
- Gram negative bacilli
- Influenza A virus
- Respiratory syncytial virus
361
Give the four atypical pneumonia pathogens.
- Mycoplasma pneumoniae
- Chlamydophila pneumonia/psittaci
- Legionella pneumophilia
- Coxiella burnetti
362
What organisms are a common cause of hospital-acquired pneumonia?
Gram negative bacteria (Eg. Klebsiella, Escherichia, Pseudomonas)
363
Give three causes of pneumonia that may occur in immunocompromised patients.
- Viral
- Mycobacteria
- Pneumocystis
364
Describe pneumonia caused by Mycoplasma.
Usually a milder illness in young adults, but may have extrapulmonary features.
365
Describe the pneumonia caused by legionella.
Severe illness with respiratory failure.
366
Where can Legionella be caught?
Warm water (water cooling towers, showers, air conditioning, travel)
367
How is Chlamydophila psittaci caught?
Contact with sick birds
368
Give another name for Coxiella burnetti pneumonia.
Q fever
369
How is Coxiella burnetti caught?
Exposure to partuent animals (sheep)
370
Give eight risk factors for pneumonia.
- Extremities of age (infants and elderly)
- COPD and certain other chronic lung diseases
- Immunocompromised
- Nursing home residents
- Impaired swallow
- Diabetes
- Congestive heart disease
- Alcoholics and IV drug abusers
371
Briefly describe the pathology of bacterial pneumonia.
- Bacteria enter normally sterile distal airway and overwhelm resident host defence
- Alveolar spaces filled with inflammatory infiltrate rich in neutrophils
372
Describe the resolution phase of bacterial pneumonia.
- Bacteria cleared
| - Inflammatory cells removed by apoptosis
373
What are the symptoms of pneumonia?
- Fever
- Rigors
- Sweats
- Productive cough
- Malaise
- Anorexia
- Dyspnoea
- Haemoptysis
- Pleuritic pain
374
Describe the typical appearance of sputum produced in S.pneumoniae infection.
Rusty
375
Give the signs of pneumonia.
- Pyrexia
- Cyanosis
- Confusion
- Tachypnoea
- Tachycardia
- Hypotension
- Signs of consolidation
- Pleural rub
376
Give five signs of pulmonary consolidation.
- Diminished expansion
- Dull percussion
- Increased vocal resonance
- Bronchial breathing
- Crackles +/- wheeze
377
Which two systems might show extrapulmonary features of Legionella pneumonia?
- Neurological
| - Gastrointestinal
378
Give an extrapulmonary feature of Mycoplasma pneumonia.
Rash
379
Give five investigations to carry out in suspected pneumonia.
- CXR
- Assess oxygenation and BP
- Blood tests and cultures
- Sputum
- Pleural fluid aspiration
380
Give three features that may be seen on a chest X ray in pneumonia.
- Lobar/multilobar infiltrates
- Cavitation
- Pleural effusion
381
How is the severity of pneumonia assessed?
CURB-65
382
What are the components of CURB-65?
- Confusion
- Urea >7mmol/L
- Respiratory rate >30/min
- BP <90 systolic
- >65yrs
383
What does a CURB-65 score of 0-1 mean?
Mild = home treatment possible
384
What does a CURB-65 score of 2 mean?
Hospital therapy
385
What does a CURB-65 score of 3+ mean?
Severe pneumonia (consider ITU)
386
What severity score is used in the community for pneumonia?
CRB-65
387
Give four management principles of pneumonia.
- Antibiotics
- Oxygen
- IV fluids
- Analgesia
388
What empirical antibiotics are used for mild pneumonia (and for penicillin allergy)?
Amoxicillin
Penicillin allergy = clarithromycin or doxycycline
389
What empirical antibiotics are given in moderate pneumonia?
Amoxicillin + Clarithromycin
390
What empirical antibiotics are given in severe pneumonia (and for penicillin allergy)?
IV co-amoxiclav + clarithromycin
PENICILLIN ALLERGY = Cefuroxime + clarithromycin
391
What antibiotics are effective against S.pneumoniae pneumonia?
- Amoxicillin
- Cefuroxime/cefotaxime if penicillin allergy
Can also use clarithromycin or ciprofloxacin
392
What antibiotics can be used for H.influenzae pneumonia?
- Co-amoxiclav
- Doxycycline
- NOT Macrolides
393
Give two antibiotics that can be used for S.aureus pneumonia.
- Flucloxacillin
| - Cefuroxime
394
Give two antibiotics that can be used for MRSA pneumonia.
- Vancomycin
| - Linezolid
395
Give two antibiotics that can be used for klebsiella pneumonia.
- Co-amoxiclav
| - Cephalosporins
396
What antibiotic should be in the regimen for Legionella pneumonia?
Ciprofloxacin
397
Give two antibiotics that can be used to treat necrotising pneumonia.
- IV linezolid
| - IV clindamycin
398
What antibiotics can be given for Pseudomonas pneumonia?
- IV ceftazidime or piperacillin-tazobactam
+
Gentamicin/tobramycin or ciprofloxacin
399
Give three antibiotics that can be used to treat atypical pneumonia pathogens.
- Erythromycin/clarithromycin
- Ciprofloxacin
- Doxycycline
400
Give nine potential complications of pneumonia.
- Respiratory failure
- Septicaemia
- Pleural effusion
- Empyema
- Lung abscess
- Brain abscess
- Pericarditis
- Myocarditis
- Cholestatic jaundice
401
Give five markers on thoracocentesis of a parapneumonic effusion that suggests empyema.
- pH<7.2
- Glucose <3.3mmol/L
- LDH >1000
- Positive gram stain or culture
- Pus or thick fluid
402
Give three choices of antibiotics for an empyema secondary to pneumonia.
- Co-amoxiclav
- Piperacillin-tazobactam
- Meropenam
403
Give three groups of people in whom lung abscesses are more common in pneumonia.
- Aspiration
- Alcoholics
- Poor dentition
404
Give four organisms that can cause lung abscesses in pneumonia.
- Streptococcus milleri
- Anaerobes
- Klebsiella pneumonia
- Other gram-negative bacteria
405
Define hospital acquired pneumonia.
Pneumonia acquired at least 48hrs after hospital admission.
406
Give three risk factors for hospital-acquired pneumonia.
- Elderly
- Ventilator
- Post-operative
407
Give five features suggestive of hospital-acquired pneumonia.
- New fever
- Purulent secretions
- New radiological infiltrates
- New leukocytosis/CRP increase
- Increased O2 requirements
408
Give four organisms which can cause late-onset hospital-acquired pneumonia.
- Staph.aureus (including MRSA)
- Pseudomonas aeruginosa
- Acinetobacter baumanii
- Klebsiella pneumoniae
409
Give three empirical antibiotics that can be used in hospital-acquired pneumonia.
- Piperacillin-tazobactam
- Meropenam
- Ceftazadime
410
Give six causes of pneumonia in immunocompromised patients.
- Pseudomonas aeruginosa
- Pneumocystis pneumonia
- Mould (Aspergillus)
- Cytomegalovirus
- Adenovirus
- Respiratory syncytial virus
411
Give five non-infectious causes of chronic pneumonia.
- Malignancy
- Vasculitis
- Chronic interstitial pneumonia
- Drugs
- Eosinophils
412
Give six common respiratory viruses.
- Rhinoviruses
- Influenza A virus
- Coronaviruses
- Adenoviruses
- Parainfluenza viruses
- Respiratory syncytial viruses
413
Give six complications of a respiratory virus.
- Sinusitis
- Pharyngitis
- Otitis media
- Bronchitis
- Rarely pneumonia
- May lead to bacterial super-infection
414
What is the proper scientific name for Tamiflu?
Oseltamiver
415
When is tamiflu indicated?
If influenza A or B virus is circulating and he patient is in an ‘at risk’ group
416
How does Tamiflu work?
Neuraminidase inhibitor (stops virus from budding out of host cell).
417
Describe the presentation of pharyngitis.
- Sore throat
- Tender glands in neck
- Fever
- Tender cervical lymph nodes
- Tonsil enlargement
418
Is pharyngitis usually bacterial or viral?
Viral
419
What are the two most common viral causes of pharyngitis?
| And two less common ones
- Rhinovirus
- Adenovirus
(- Epstein Barr virus)
(- acute HIV infection)
420
Give six bacterial causes of pharyngitis.
- Streptococcus pyogenes
- Other Streptococci
- Mycoplasma pneumoniae
- Neisseria gonorrhoea (and other STIs)
- Fusobacterium necrophorum
- Corynebacterium diphtheria
421
Give three complications of Strep.pyogenes pharyngitis.
- Scarlet fever
- Post-streptococcal glomerulonephritis
- Rheumatic fever
422
Give five features of rheumatic fever.
- Carditis
- Arthritis
- Chorea
- Erythema marginatum
- Subcutaneous nodules
423
What is the treatment for bacterial pharyngitis?
Amoxicillin
424
What is the treatment for Corynebacterium diphtheriae pharyngitis?
Anti-toxin and erythromycin
425
Give the four Centor criteria which favour a bacterial causes of a sore throat over a viral cause.
- Tonsillar exudate
- Tender anterior cervical adenopathy
- Fever over 38
- Absence of cough
426
Describe the presentation of sinusitis.
- Fever
- Facial pain
- Purulent nasal discharge
- May have pain in ears and teeth
427
Is sinusitis usually bacterial or viral?
Viral
428
Give four bacterial causes of sinusitis.
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Streptococci
429
Give four features of sinusitis that make a bacterial cause more likely.
- Unilateral pain
- Purulent discharge
- Fever >10days
- Acute presentation with complications
430
Give three complications of sinusitis.
- Brain abscess
- Sinus vein thrombosis
- Orbital cellulitis
431
Describe the clinical presentation of epiglottitis.
- Sore throat
- Pain on swallowing (odynophagia)
- Fever
- Inspiratory stridor
432
What is the most common causative organism of epiglottitis?
Haemophilus influenzae
433
What is the standard treatment for epiglottitis?
Amoxicillin (but 20% produce beta-lactamase, so use doxycycline or co-amoxiclav)
434
Which antibiotics is Haemophilus influenzae not susceptible to?
Macrolides
435
How long is the incubation phase for whooping cough?
7-10days
436
What are the two phases of whooping cough and how long do they last for?
```
Catarrhal phase (1-2weeks)
Paroxysmal phase (1-6weeks)
```
437
What are the symptoms in the catarrhal phase of whooping cough?
- Rhinorrhoea
- Conjunctivitis
- Low-grade fever
- Lymphocytosis
438
What are the symptoms in the paroxysmal phase of whooping cough?
- Coughing spasms
- Inspiratory ‘whoop’
- Post-ptussive vomiting
- Cough >14days
439
What is the causative organism of whooping cough?
Bordatella pertussis
440
Give four diagnostic techniques that can be used in whooping cough.
- Culture
- PCR
- ELISA
- IgG
441
Give three complications of whooping cough.
- Pneumonia
- Encephalopathy
- Subconjunctival haemorrhage
442
What antibiotics are used to treat whooping cough?
Clarithromycin
443
What is another name for croup?
Acute laryngo-tracheobronchitis
444
What age group gets croup?
Children
445
What is the most common cause of croup?
Parainfluenza viruses
446
Give 2 less common causes of croup.
- Respiratory syncytial virus
| - Influenza A
447
Describe the presentation of croup.
- Barking cough
- Fever
- Cyanosis
- Tachypnoea
- Inspiratory stridor
448
What are the two most common causes of the common cold?
- Rhinoviruses
| - Coronaviruses
449
What are the two most common viral causes of a sore throat?
- Adenoviruses
| - Epstein-Barr virus
450
What is the most common cause of influenza?
Influenza A and B
451
What is the most common viral cause of acute bronchitis?
Adenoviruses
452
What are three common viral causes of chronic bronchitis?
- Respiratory syncytial virus
- Rhinoviruses
- Parainfluenza viruses
453
What are two common viral causes of bronchiolitis?
- Respiratory syncytial virus
| - Adenoviruses
454
Define influenza.
Acute respiratory illness caused by an infection with influenza viruses.
455
What family are the influenza viruses part of?
Orthomyxoviridae (bird viruses)
456
Give the three genera of the influenza virus.
- Influenza A
- Influenza B
- Influenza C
457
What are the four key antigenic sites on the influenza virus?
- Haemagglutinin
- Neuraminidase
- M2 ion channel
- Ribonucleoprotein
458
Which influenza viruses cause disease in humans?
Influenza A and Influenza B
459
Describe the influenza viral genome structure.
8 single-stranded RNA segments
460
How does the influenza virus change its genome so much?
Gene re-assortment can occur in infections, and gene swapping can occur during co-infection with human and avian flu virus in human and pigs.
461
Describe antigenic drift and its consequences.
- Minor antigenic variation
| - Causes seasonal epidemics
462
What is an epidemic?
More cases in one area
463
Describe antigenic shift and its consequences.
- Gene reassortment and major antigenic variation
| - Associated with pandemics
464
What is a pandemic?
An epidemic which crosses international borders
465
What haemagglutinin and neuraminidase subtypes of the influenza A virus are humans infected by?
H1/H2/H3
| N1/N2
466
Describe the disease caused by the Influenza A virus.
Severe and extensive outbreaks and pandemics
467
Describe the outbreaks associated with the influenza B virus.
Tends to cause sporadic, less severe outbreaks (schools, care homes, garrisons)
468
What age group is Influenza B more commonly seen in?
Children
469
Describe the disease that is caused by the Influenza C virus.
- Relatively minor disease
| - Mild symptoms or asymptomatic
470
How is influenza transmitted?
Mainly via aerosols (coughs/sneezes)
| - Also possible via hand-to-hand contact, other personal contact, or fomites
471
Describe what causes seasonal flu.
Each year the virus undergoes antigenic drift
472
What causes pandemic flu?
Virus mutates markedly (antigenic shift)
473
Give three risks which may lead to a flu pandemic.
- More travel
- More people
- Intensive farming (more animal contacts with people, factory farming ‘breeds’ viruses)
474
Give four consequences of a flu pandemic.
- High morbidity
- Excess mortality
- Social disruption
- Economic disruption
475
Who is more likely to be killed in a flu pandemic and why?
Young people - older people may be more immune
476
What are the symptoms of flu?
- Upper and/or lower respiratory tract symptoms
- Fever
- Headache
- Myalgia
- Weakness
477
Give a complication of flu.
Bacterial pneumonia
478
Give six risk factors for mortality in the flu.
- Chronic cardiac and pulmonary diseases
- Meningitis (synergistic effects between flu and meningitis)
- Old age
- Chronic metabolic diseases
- Chronic renal disease
- Immunosuppressed
479
Give four principles of supportive care in flu.
- Oxygenation
- Hydration/nutrition
- Maintain homeostasis
- Prevent/treat secondary infections
480
Give two coronaviruses.
- SARS coronavirus
| - MERS coronavirus
481
What is SARS?
Severe acute respiratory syndrome
482
What is MERS?
Middle Eastern Respiratory Syndrome
483
What is bronchiolitis?
Airways obstruction due to inflammation of the bronchioles and mucus production.
484
What is the most common causative organism of bronchiolitis?
Respiratory syncytial virus (RSV)
485
What age group does bronchiolitis affect?
Babies and small children
486
Define bronchitis.
Self-limited inflammation of the epithelium of the bronchi due to upper airway infection.
487
Is bronchitis usually bacterial or viral?
Viral
488
Give three potential (but rare) causes of bronchitis.
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Bordatella pertussis
489
Give three symptoms of bronchitis.
- Cough (may be productive or non-productive)
- SOB
- Wheeze
490
Where is focal consolidation found in bronchitis?
No signs of focal consolidation are found
491
What are the systemic features that usually occur in bronchitis?
Fever/systemic features are unusual
492
Describe the CXR in bronchitis.
Normal
493
What is the treatment for bronchitis?
Usually none, especially if viral
494
Define bronchiectasis.
An abnormal permanent dilation of the bronchi accompanied by inflammation in their walls and in adjacent lung parenchyma.
495
In which countries is bronchiectasis more common?
Less developed countries
496
In general, what causes bronchiectasis?
Chronic inflammation of bronchi and bronchioles.
497
Give eleven causes of chronic inflammation that can lead to bronchiectasis.
- Idiopathic
- Obstruction (tumour, foreign body)
- Cystic fibrosis
- Young’s syndrome
- Primary ciliary dyskinesia
- Kartagener’s syndrome
- Post-infection
- Allergic bronchopulmonary aspergillosis
- Hypogammaglobulinaemia
- Rheumatoid arthritis
- Ulcerative colitis
498
Give two infections that can lead to bronchiectasis.
- Whooping cough
| - TB
499
Give five organisms that colonise the respiratory tract and can cause infections in bronchiectasis.
- Haemophilus influenzae
- Streptococcus pneumoniae
- Staphylococcus aureus
- Moraxella catarrhalis
- Pseudomonas aeruginosa
500
Briefly describe the pathogenesis of bronchiectasis.
- Recurrent inflammation weakens bronchial walls
- Scarring in adjacent lung parenchyma places traction on weakened bronchi
- Bronchi permanently dilate
501
What are the symptoms of bronchiectasis?
- Persistent productive cough
| - Haemoptysis
502
Give three signs of bronchiectasis.
- Finger clubbing
- Course inspiratory crepitations
- Wheeze
503
Give five investigations to carry out in bronchiectasis.
- Sputum culture
- CXR
- High resolution CT (HRCT) chest
- Spirometry
- Bronchoscopy
504
Give two CXR findings in bronchiectasis.
- Cystic shadows
| - Thickened bronchial walls
505
Why would a high resolution CT chest be carried out in bronchiectasis?
Assess extent and distribution of disease
506
What pattern would be seen on spirometry in bronchiectasis?
Obstructive
507
Give three reasons why bronchoscopy is carried out in bronchiectasis.
- Locate site of haemoptysis
- Exclude obstruction
- Obtain samples for culture
508
Give two microscopic findings in bronchiectasis.
- Visibly dilated airways
| - Airways filled with macropurulent material
509
Give three microscopic findings in bronchiectasis.
- Chronic inflammation in bronchial walls
- Lymphoid aggregates
- Adjacent alveoli may show acute and organising pneumonia
510
Give five management options for bronchiectasis.
- Postural drainage/chest physiotherapy
- Antibiotics
- Bronchodilators
- Corticosteroids (for allergic bronchopulmonary aspergillosis)
- Surgery
511
Give two indications for surgery in bronchiectasis.
- Localised disease
| - Severe haemoptysis
512
Give eight potential complications of bronchiectasis.
- Pulmonary hypertension
- Right ventricular failure
- AA (serum amyloid A) amyloidosis
- Pneumonia
- Pleural effusion
- Pneumothorax
- Cerebral abscess
- Haemoptysis
513
What is a pneumothorax?
Presence of air in the pleural space.
514
Are pneumothoraces more common in men or women?
Men
515
Give some causes of pneumothorax.
- Spontaneous
- COPD
- Asthma
- Pneumonia
- Tuberculosis
- Cystic fibrosis
- Sarcoidosis
- Lung carcinoma
- Idiopathic pulmonary fibrosis
- Trauma (penetrating chest wound, rib fractures)
- Iatrogenic (subclavian vein cannulation, lung biopsy)
516
Describe when spontaneous pneumothorax is typically seen.
Typically seen in thin tall young men, due to rupture of small apical delicate blebs of lung tissue which result from stretching of the lung.
517
Describe the pathology of a pneumothorax.
- Air leaks out of damaged lung into pleural space until pressures equalise
- Lung collapses to a variable degree
518
Describe a tension pneumothorax.
- Tissues near lung defect act as a one way valve
- Pressure/volume builds up in pleural space
- Displacement of mediastinal structures, causing cardiorespiratory arrest
519
What are the symptoms of a pneumothorax?
- Sudden onset unilateral pleuritic chest pain
- Dyspnoea
- Worsening of symptoms in pre-existing lung condition
520
What are the signs of a pneumothorax?
- Reduced expansion
- Hyper-resonance to percussion
- Diminished breath sounds
- Trachea deviated away from affected side in tension pneumothorax
521
What investigation should be carried out in a pneumothorax, and when shouldn’t it be done?
CXR
| *Don’t do it suspected tension pneumothorax as it delays treatment
522
Give two findings on CXR in pneumothorax.
- Air present in pleural space
| - Varying amounts of lung collapse
523
Give two management options for a pneumothorax.
- Aspiration
| - Chest drain
524
Give four indications for surgery in a pneumothorax.
- Bilateral pneumothoraces
- Lung fails to expand after intercostal drain insertion
- 2 or more previous pneumothoraces on same side
- History of pneumothorax on opposite side
525
What proportion of patients with a spontaneous pneumothorax suffer recurrent episodes?
1/3
526
Give two things that can cause acute airways obstruction.
- Tumour
| - Foreign body
527
Give two things that acute airways obstruction can cause in the lungs.
- Distal collapse (atelectasis)
| - Over-expansion (valve effect)
528
What do the pulmonary function tests usually show in acute airways obstruction?
They are usually normal
529
Give two potential complications of acute airways obstruction.
- Infective pneumonia
| - Bronchiectasis
530
Give two types of chronic airways obstruction.
- COPD
| - Asthma
531
Define COPD.
A chronic lung condition characterised by breathlessness due to poorly reversible and progressive airflow obstruction.
532
What three specific conditions does COPD entail?
- Chronic bronchitis
- Bronchiolitis
- Emphysema
533
Define emphysema.
Enlarged airspaces distal to terminal bronchioles, with destruction of alveolar walls.
534
Define chronic bronchitis.
Prolonged cough and sputum production (most days for 3 months of 2 successive years).
535
Give three groups of people in whom COPD is more common.
- Middle-aged/elderly
- Smokers
- Males
536
What is the most common cause of COPD?
Smoking
537
What is a common cause of COPD in younger individuals?
A1-antitrypsin deficiency
538
Briefly describe the pathology of emphysema.
- Imbalance of proteases and antiproteases causes destruction of lung parenchyma with dilation of terminal air spaces and air trapping
- Enlargement of alveolar airspaces and destruction of elastin in walls
539
Describe the pathology in chronic bronchitis/bronchiolitis.
- Inflammation and scarring of small bronchioles
- Mucus gland hyperplasia and chronic inflammation (effects of smoke) causes productive cough
- Irritation and inflammation lead to squamous metaplasia
540
Give five bacteria which cause recurrent low grade bronchial infections in COPD.
- Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
541
Give six viruses that cause infections in COPD.
- Respiratory syncytial virus
- Adenovirus
- Rhinovirus
- Coronavirus
- Influenza
- Parainfluenza
542
Give five characteristics of COPD.
- Airflow obstruction
- Usually progressive
- Not fully reversible
- Doesn’t change markedly over several months
- Predominantly caused by smoking
543
What are the symptoms of COPD?
- Cough
- Sputum
- Dyspnoea
- Wheeze
544
What are the signs of COPD?
- Tachypnoea
- Use of accessory muscles of respiration
- Hyperinflation
- Decreased cricosternal distance
- Decreased lung expansion
- Resonant or hyperresonant percussion note
- Quiet breath sounds
- Wheeze
- Cyanosis
- Cor pulmonale
- Weight loss
545
Describe pink puffers.
- More alveolar ventilation
- Near normal PaO2
- Normal or low PaCO2
- Breathless but not cyanosed
- May progress to type 1 respiratory failure
- More emphysema
546
Describe blue bloaters.
- Decreased alveolar ventilation
- Low PaO2
- High PaCO2
- Cyanosed but not breathless
- May develop Cor pulmonale
- Rely on hypoxic drive to maintain respiratory effort
- More bronchitis
547
Give four macroscopic findings in the lungs in COPD.
- Hyperinflated lungs
- Thick mucus in airways
- Dilated terminal airspaces
- Bullae may be present
548
Give four microscopic findings on the lungs in COPD.
- Chronic inflammation and fibrosis of small bronchioles
- Finely pigmented macrophages in respiratory bronchioles
- Dilated terminal airspaces
- Larger airways show mucus gland hyperplasia
549
Give four investigations to perform in COPD.
- CXR
- Spirometry
- ECG
- ABG
550
Give five potential CXR findings in COPD.
- Hyperinflation
- Flat hemidiaphragms
- Large central pulmonary arteries
- Decreased peripheral vascular markings
- Bullae
551
Give four findings on spirometry in COPD.
- Obstructive
- Low FEV1 (<80%)
- Low FEV1/FVC ratio (<0.7)
- Scalloping of flow-volume curve
552
What may be seen on an ECG in COPD?
Right atrial and ventricular hypertrophy
553
What may be seen on an ABG in COPD?
Decreased PaO2 +/- hypercapnia
554
Give seven differential diagnoses of COPD.
- Other causes of SOB
- Heart failure
- Pulmonary embolus
- Pneumonia
- Lung cancer
- Asthma
- Bronchiectasis
555
Describe stage 1 COPD.
FEV1 >80% of normal (mild)
556
Describe stage 2 COPD.
FEV1 50-79% of normal (moderate)
557
Describe stage 3 COPD.
FEV1 30-49% of normal (severe)
558
Describe stage 4 COPD.
FEV1 <30% of normal (very severe)
559
What is stage 1 of the MRC dyspnoea scale?
SOB on marked exertion
560
What is stage 2 of the MRC dyspnoea scale?
SOB on hills
561
What is stage 3 of the MRC dyspnoea scale?
Slow or stop on flat
562
What is stage 4 of the MRC dyspnoea scale?
Exercise tolerance 100-200 yards on flat
563
What is stage 5 of the MRC dyspnoea scale?
Housebound/SOB on minor tasks
564
Name two methods of evaluating symptom severity in COPD.
- MRC dyspnoea scale
| - CAT (COPD assessment test)
565
What 2 criteria are needed to be ranked ‘A’ in the combined assessment of COPD?
- MRC 1-2 or CAT <10
| - Up to 1 exacerbation in past year, not needing hospitalisation
566
What 2 criteria are needed to be ranked ‘B’ in the combined assessment of COPD?
- MRC3+ or CAT>10
| - Up to 1 exacerbation in last year, not needing hospitalisation
567
What 2 criteria are needed to be ranked ‘C’ in the combined assessment of COPD?
- MRC1-2 or CAT<10
| - An exacerbation in the last year needing hospitalisation, or more than one exacerbation
568
What 2 criteria are needed to be ranked ‘D’ in the combined assessment of COPD?
- MRC3+ or CAT>10
| - An exacerbation in the last year needing hospitalisation, or more than one exacerbation
569
Give five non-pharmacological treatments for COPD.
- Stop smoking
- Exercise
- Treat poor nutrition or obesity
- Influenza and pneumococcal vaccination
- Pulmonary rehabilitation/palliative care
570
What treatment can be given to mild COPD?
Short-acting antimuscarinic or beta-2 agonist
571
What treatment can be given in moderate/severe COPD?
Long-acting antimuscarinic/beta-2 agonist + corticosteroid
572
Give four management options for advanced COPD.
- Long term oxygen therapy (LTOT)
- Ventilatory support (NIV/Bi-PAP)
- Lung volume reduction surgery
- Lung transplant
573
What is an acute exacerbation of COPD?
Acute event characterised by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variation and leads to a change in medications.
574
Give three common causes of exacerbations of COPD.
- Viral infection
- Bacterial infection
- Pollutants
575
Give five management steps in the treatment of acute exacerbations of COPD.
- Nebulized bronchodilators (short acting beta2/antimuscarinics)
- Controlled oxygen therapy
- Steroids (IV hydrocortisone and oral prednisolone)
- Antibiotics if evidence of an infection
- Physiotherapy for sputum
576
What oxygen sats should be aimed for in COPD?
88-92%
577
Give three indications for antibiotics in acute exacerbations of COPD.
- Increased dyspnoea
- Increased sputum volume
- Increased sputum purulence
578
Give seven potential complications of COPD.
- Acute exacerbations
- Infections
- Polycythaemia
- Respiratory failure
- Cor pulmonale
- Pneumothorax
- Lung carcinoma
579
Describe how Cor pulmonale occurs in COPD.
Pulmonary hypertension occurs due to obliteration and vasoconstriction.
580
What is the most common cause of death in COPD?
Combination of respiratory and cardiac failure.
581
Define respiratory failure.
Inability of the lungs to adequately oxygenate the arterial blood supply, and/or eliminate CO2 from the venous blood supply.
582
What is type 1 respiratory failure?
Low O2 (lung failure)
583
What is type 2 respiratory failure?
Low O2 + high CO2 (pump failure)
584
What is a low O2 defined as?
<8kPa
585
Give six general causes of type 1 respiratory failure.
| Which is the most common?
- Reduced FiO2
- V/Q mismatch (most common)
- Increased shunt
- Diffusion impairment
- Airways obstruction
- Alveolar hypoventilation
586
Give three causes of diffusion impairment which may result in type 1 respiratory failure.
- Emphysema
- Interstitial lung disease
- Drug-induced lung disease
587
Describe the mechanism that usually causes type 2 respiratory failure?
Alveolar hypoventilation (CO2 enters the alveoli but is not removed)
588
What is the normal V/Q?
0.8
589
Describe dead space?
Infinate V/Q
| Normal alveolus but no blood supply
590
Describe shunt (when applied to the lungs).
V/Q = 0
| Normal blood supply but no oxygen
591
Give seven causes of a V/Q mismatch.
- Pneumonia
- Pulmonary oedema
- PE
- Asthma
- Emphysema
- Pulmonary fibrosis
- Adult respiratory distress syndrome
592
Give six causes of alveolar hypoventilation.
- Airways obstruction
- Airway secretions
- Obesity/obstructive sleep apnoea
- Chest wall abnormalities
- Neuromuscular disorders
- Central sleep apnoeas
593
Give three neuromuscular disorders which can cause alveolar hypoventilation.
- Myasthenia gravis
- Motor neurone disease
- Guillan-Barre syndrome
594
What are the signs of type 1 respiratory failure?
- Cyanosis
- Tachypnoea
- Accessory muscle use
- Tachycardia
- Signs of underlying disease
- Confusion
595
What are the signs of hypercapnia/type 2 respiratory failure?
- Bounding pulse
- Flapping tremor
- Confusion
- Drowsiness
- Reduced consciousness
596
What is the treatment for type 1 respiratory failure?
- Oxygen
- Treat underlying cause
- CPAP (if unable to maintain adequate oxygenation)
597
What O2 sats would be aimed for in type 1 respiratory failure?
94-98%
598
What is the treatment for type 2 respiratory failure?
- Oxygen
- Treat underlying cause
- NIV (if unable to maintain oxygenation or removal of CO2)
599
What O2 sats are aimed for in type 2 respiratory failure and why?
88-92%
| Respiratory drive may become insensitive to CO2 so patient relies on hypoxia to maintain respiratory drive
600
If a patient comes into hospital in an emergency and they have respiratory failure, what sats do you aim for?
88-92% until ABG results are back
601
Describe CPAP.
Positive pressure applied thought the respiratory cycle to increase pressure in the airways.
It prevents airway collapse and decreases work of breathing.
602
Describe NIV.
Biphasic positive airways pressure that aids alveolar ventilation.
603
In which types of respiratory failure would CPAP and NIV be used?
```
CPAP = type 1
NIV = type 2
```
604
What is the route of administration for the antibodies used to treat asthma?
Subcutaneous
605
Give two diseases that bronchoconstriction is a feature of.
- Asthma
| - COPD
606
Give four respiratory diseases that inflammation is a part of.
- Pneumonia
- Asthma
- COPD
- Idiopathic pulmonary fibrosis
607
Give three respiratory diseases that bronchiectasis is a feature of.
- Asthma
- Cystic fibrosis
- COPD
608
Inhalers deliver drugs in what formulation?
Dry powder
609
Give three different types of inhaler devices.
- Pressurised metered-dose inhalers
- Spacers
- Dry powder inhaler
610
Pressurised metered-dose inhalers release a spray containing what two things?
Drug and propellant
611
How do spacers work?
Slow down drug particles and allow more time for evaporation of the propellant so more drug is inhaled.
612
Nebulisers deliver drugs in what formulation?
Aerosols
613
Give two advantages of nebulisers compared to inhalers.
- No coordination required by the user
| - Can use high doses
614
Give three reasons why delivery of drugs to the conducting airways instead of the respiratory region of the lungs is not as effective.
- Smaller surface area
- Lower regional blood supply
- High filtering capacity (mucus/cilia)
615
Describe the size of the drug particles required to get a drug to the respiratory region of the lungs.
Particles need to be small
616
Give eight advantages of inhaled medications.
- Lungs are robust so can handle repeated drug exposure
- Lungs are naturally permeable to peptides
- Large surface area
- Rapid absorption of small hydrophobic particles
- Drugs can act directly on lung or enter circulation
- 2nd fastest systemic uptake and non-invasive
- Fewer drug metabolising enzymes (smaller doses)
- Fewer systemic side effects
617
Is it better to use a nasal or inhalational route of administration?
Inhalation
618
What does too forceful inhalation when using an inhaler result in?
Deposition in upper airways instead of lungs.
619
Name two new drugs that are being used in idiopathic pulmonary fibrosis.
- Pirfenidone
| - Nintedanib
620
Give three ways that pirfenidone works in idiopathic pulmonary fibrosis.
- Reduces fibroblast proliferation
- Reduces collagen production
- Reduces production of fibrogenic mediators
621
What type of drug is nintedanib?
Tyrosine kinase inhibitor
622
Give four receptors/pathways that nintedanib inhibits in idiopathic pulmonary fibrosis.
- Vascular endothelial growth factor receptor (VEGFR)
- Transforming growth factor beta (TGF-b)
- Platelet derived growth factor (PDGF)
- Fibroblast growth factor (FGF-2)
623
Name two types of bronchodilators.
- Beta2 agonists
| - Muscarinic antagonists
624
Give two actions of beta2 agonists.
- Cause smooth muscle relaxation and bronchodilation
| - Inhibit histamine release from lung mast cells
625
Give three categories of beta2 agonist.
- Short acting (SABA)
- Long acting (LABA)
- Ultra LABA
626
What is the advantage of ultra LABA?
Allow once-daily dosing
627
Give an example of a SABA.
Salbutamol
628
Give two examples of LABAs.
- Formoterol
| - Salmeterol
629
Give two examples of ultra LABAs.
- Indacaterol
| - Olodaterol
630
Give two indications for bronchodilators, and what other drugs they are combined with.
- LABA + corticosteroids for asthma
| - LABA + LAMA for COPD
631
Give two actions of muscarinic antagonists.
- Prevent muscle contraction and gland secretion
| - Enhance neurotransmitter release
632
Name a naturally-occurring anticholinergic.
Atropine
633
Give two examples of newer synthetic derivatives of antimuscarinics that are used as bronchodilators.
- Ipratropium bromide
| - Tiotropium bromide
634
What is the advantage of using new synthetic derivatives of anticholinergics instead to atropine?
Fewer side effects
635
When are muscarinic antagonists used, and what are they used with?
Used with steroids to treat asthma and COPD.
636
Give three actions of corticosteroids in lung disease.
- Improve lung function and QoL in asthma
- Reduce frequency of exacerbations
- Can prevent irreversible airway changes
637
Why may steroids not be as effective in severe asthma?
Severe asthmatics may become resistant.
638
Give three lung diseases in which steroids are relatively ineffective.
- COPD
- Cystic fibrosis
- Idiopathic pulmonary fibrosis
639
What are steroids relatively ineffective in COPD?
Most patients are resistant
640
Give five examples of inhaled corticosteroids used in respiratory medicine.
- Beclomethasone dipropionate
- Budesenide
- Ciclesonide
- Flucticasone propionate
- Mometasone furoate
641
Give four mechanisms of action of steroids in lung diseases.
- Suppress production of chemotactic mediators
- Reduce adhesion molecule expression
- Inhibit inflammatory cell survival in the airway
- Inhibit Nf-kB pathway
642
Describe the two aspects of bronchodilator and corticosteroid synergism.
- Glucocorticoids increase transcription of b2 receptor gene
| - LABAs increase translocation of steroids from cytoplasm to nucleus
643
What is extrinsic allergic alveolitis/hypersensitivity pneumonitis?
An interstitial lung disease caused by an immunologic reaction to inhaled antigens.
644
Is hypersensitivity pneumonitis more common in smokers or non-smokers?
Non-smokers
645
Give five causes of hypersensitivity pneumonitis.
- Mouldy hay
- Compost
- Air conditioner ducts
- Fungi
- Bird droppings/feathers
646
Give four examples of hypersensitivity pneumonitis caused by fungi.
- Farmer’s lung
- Malt worker’s lung
- Mushroom worker’s lung
- Sugar worker’s lung
647
Give two examples of hypersensitivity pneumonitis caused by bird droppings/feathers.
- Bird-fancier’s lung
| - Pigeon-fancier’s lung
648
Briefly describe the pathology of hypersensitivity pneumonitis.
- Inhaled antigens lead to an abnormal immune reaction in the lungs
- Involves a combination of immune complex (type 3) and cell-mediated (type 4) hypersensitivity reactions
649
Describe the acute presentation of hypersensitivity pneumonitis 4-6hrs after a large exposure.
- Severe breathlessness
- Dry cough
- Crackles (no wheeze)
- Fever
- Rigors
- Myalgia
* Resolution typically within 12-18hrs after exposure
650
When does hypersensitivity pneumonitis cause chronic disease?
Prolonged exposure to small amounts of antigen.
651
Describe the presentation of chronic hypersensitivity pneumonitis.
- Breathlessness
- Dry cough
- Fatigue
- Weight loss
- Exertional dyspnoea
- Type 1 respiratory failure
- Cor pulmonale
652
Give three microscopic appearances that may be seen in hypersensitivity pneumonitis.
- Cellular chronic interstitial pneumonia
- Peribronchiolar accentuation
- Foci of organising pneumonia and poorly formed granulomas may also be present
653
Give four investigations to carry out in hypersensitivity pneumonitis.
- Bloods
- Arterial blood gas
- High resolution CT
- Lung function tests
654
Give three things to look for on a blood test in hypersensitivity pneumonitis.
- Neutrophilia
- Increased ESR
- Serum precipitins
655
Give three things that may be seen on a high resolution CT in hypersensitivity pneumonitis.
- Middle to upper long mottling/consolidation
- Hilar lymphadenopathy
- May also see traction bronchiectasis and honeycomb areas
656
What may the lung function tests show in hypersensitivity pneumonitis?
- Reversible restrictive deficit
| - Reduced TLco during acute attacks
657
Describe the acute management of hypersensitivity pneumonitis.
- Remove allergen
- Give O2
- Oral prednisolone
658
Describe the management for chronic hypersensitivity pneumonitis.
- Avoid allergen exposure
- Wear facemask or positive pressure helmet
- Long term steroids
659
Give two consequences of persistent exposure in hypersensitivity pneumonitis.
- Irreversible lung fibrosis
| - Respiratory failure
660
Define occupational lung disorders.
Respiratory conditions caused by inhaling a harmful substance (inhalable particles, gases, and vapours) in the workplace.
661
Give an example of an immediate effect of an occupational lung disorder.
High dose exposure to chlorine gas leads to acute airway injury and chronic asthma.
662
What is the significance of a condition having a shorter latency period on repeated exposure occupational lung disorders?
The patient might still be in the job so exposure may still be occurring.
663
Give seven consequences of occupational lung disorders.
- Unemployment
- Loss of earnings
- Loss of self worth
- Chronic respiratory ill health
- Depression
- Breakdown of relationships
- Compensation
664
Which regulation makes prevention of occupational lung disorders a legal requirement?
Control of substances hazardous to health regulations 2002 (COSHH)
665
Give three methods of prevention of occupational lung disorders.
- Risk assessment
- Prevent or minimise exposure to harmful substances
- Surveillance if residual risk
666
Give four ways of preventing or minimising exposure to harmful substances in the workplace.
- Elimination
- Substitution
- Engineering controls
- PPE
667
Give four causes of occupational asthma.
- Flour (bakers)
- Wood
- Metal working fluids
- Isocyanate paint
668
How is occupational asthma diagnosed?
- Normal method of asthma diagnosis
| - Difference in peak flow measurements between work and home
669
Give three characteristic features of occupational asthma.
- Latent period
- Deteriorating symptoms
- Gradual improvement (when away from work)
670
Give a consequence of occupational asthma.
Depression
671
Up until what time period (decade) were workers exposed to asbestos?
1980s
672
Give three occupations which were very exposed to asbestos.
- Electrician
- Plumber
- Joiner
673
What are pleural plaques?
Layers of collagen which are often calcified
674
What do pleural plaques indicate?
They are a harmless marker of asbestos exposure.
675
What do pleural plaques lead to?
Not cancer
676
Describe asbestosis.
Interstitial lung disease with a long latency
677
Describe the typical working history in asbestosis.
Usually have a history of heavy exposure to asbestos.
678
How does asbestosis usually present?
Progressive breathlessness
679
How is asbestosis treated?
No effective treatment
680
Describe the prognosis in asbestosis.
May progress slowly (without further exposure)
681
Give four conditions in which haemoptysis occurs.
- Pneumonia
- Bronchiectasis
- Lung cancer
- Pulmonary embolism
682
Does haemoptysis occur in COPD?
Not normally
683
Why does haemoptysis occur in bronchiectasis?
Damage to the surrounding vasculature
684
Give a condition which is defined by impaired mucociliary clearance.
Primary ciliary dyskinesia
685
Describe the age of onset of primary ciliary dyskinesia.
Congenital (childhood)
686
Describe the TLco in anaemia.
Reduced
687
Describe the TLco in asthma.
Normal
688
What is shock usually heralded by in PE?
Syncope
689
Describe the mechanism by which lung cancer causes Horner’s syndrome.
Compression of the recurrent laryngeal nerve
690
Give five things that are seen on an X-ray, in order of blackest to whitest.
- Air
- Fat
- Soft tissue or fluid
- Calcium
- Metal
691
Give four lung X ray abnormalities of increased density.
- Consolidation
- Interstitial
- Atelectasis
- Nodules and masses
692
Give three radiographical patterns of lung consolidation.
- Lobar
- Diffuse
- Multifocal
693
Give four substances that can cause lung consolidation.
- Water
- Pus
- Blood
- Cells
694
Give four causes of lung consolidation due to water.
- Heart failure
- ARDS
- Hypoalbuminaemia
- Renal failure
695
Give a cause of lung consolidation due to pus.
Pneumonia
696
Give three causes of lung consolidation due to blood.
- Trauma
- Goodpasture
- SLE
697
Give three causes of lung consolidation due to cells.
- Carcinoma
- Organising pneumonia
- Sarcoidosis
698
What modality of radiological imaging is it best to see interstitial pattern of disease?
High resolution CT
699
Give three patterns of radiographical interstitial changes.
- Reticular
- Cystic
- Fine nodular
700
Give three causes of reticular interstitial changes on lung radiography.
- Oedema
- Interstitial pneumonia
- Lymphangiitis
701
Give three causes of fine nodular interstitial changes on lung radiography.
- Sarcoidosis
- Metastases
- TB
702
What is atelectasis?
Collapse of part of a lung.
703
Give five causes of atelectasis.
- Mucous plugging
- Tumour
- Foreign body
- Pleural effusion
- Pneumothorax
704
Give two patterns of nodules/masses on lung radiology.
- Solitary pulmonary nodule
| - Multiple masses
705
What is the most common cause of a nodule/mass on lung radiology?
Granuloma
706
Give five causes of nodules/masses on lung radiography.
- Granuloma
- Bronchial carcinoma
- Metastasis
- Organising pneumonia
- Hamartoma
707
Give three radiographical lung abnormalities of decreased density.
- Cavity
- Cyst
- Emphysema
708
What does a cavity look like on Xray?
Lucency with a thick wall (>3mm)
709
What does a cyst look like on Xray?
Lucency with a thin wall (<3mm)
710
What does emphysema look like on an Xray?
Lucency without a visible wall.
711
What can a lung cavity on Xray be the result of?
Necrosis
712
Give three conditions that can cause a lung cavity on Xray.
- Infection
- Neoplasm
- Lung infarction
713
Give three things that can cause lung cysts on Xray.
- Congenital
- Bulla
- Pneumatocele
714
What is silhouette sign on lung radiography?
Refers to the loss of borders between thoracic structures.
715
Give two criteria for silhouette sign to be seen on a radiograph.
- Two objects must be in contact with each other
| - They must have the same radiographic density
716
What is phlegm?
Secretions from the respiratory tract.
717
What is sputum?
Secretions that are obtained via the mouth (may contain phlegm and saliva)
718
What is the usual cause of a loud, brassy cough?
Pressure on the trachea
719
What is the usual cause of a hollow, ‘bovine’ cough?
Recurrent laryngeal nerve palsy
720
What is the usual cause of a barking cough?
Croup
721
Give two causes of dry, chronic coughing.
- Acid irritation of the lungs (oesophageal reflux)
| - ACEi
722
Give four causes of acute SOB.
- Foreign body
- Pneumothorax
- Pulmonary embolus
- Acute pulmonary oedema
723
Give three causes of subacute SOB.
- Asthma
- Parenchymal disease
- Effusion
724
Describe phlegm and sputum production in asthma.
More phlegm is produced but not more sputum because cilia are less efficient.
