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3b/4 > respiratory > Flashcards

respiratory Flashcards

1
Q

define asthma:

A

common chronic inflammatory disorder of the airways characterised by reversible airflow limitation, airway hyperresponsiveness and bronchi inflammation

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2
Q

what is atopy?

A

genetic predisposition to IgE-mediated allergen sensitivity

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3
Q

atopic triad includes:

A

asthma
rhinitis
dermititis

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4
Q

what is the hygiene hypothesis?

A

epidemiology shows increased autoimmune and allergic responses in developed countries
reduced exposure to infectious pathogens at an early age predisposes individuals to such diseases
encourages Th2 predominant response ->IgE

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5
Q

patients with aspirin induced asthma commonly exhibit Samter’s triad, what is this?

A

asthma
aspirin sensitivity
nasal polyps

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6
Q

how are the different types of sensitisers of occupational induced asthma categorized?

A

low molecular weight

high molecular weight

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7
Q

how do low molecular weight compounds trigger asthma in occupational setting:

A

produce IgE mediated hypersensitivity response

the effects are immediate/soon after exposure

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8
Q

examples of low molecular weight triggers of asthma:

A

flour

latex

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9
Q

how do high molecular weight compounds trigger occupational asthma:

A

compounds develop a complex immune response after long term repeated exposure to the compound

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10
Q

examples of high molecular weight compounds which trigger asthma:

A

wood dust, isocyanates

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11
Q

what is the key to dx occupational asthma:

A

peak flow diaries used during periods of work and holiday

refer to specialist

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12
Q

what exposures contribute to exercise induced asthma:

A

cold air exposure

environmental pollutants

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13
Q

what is the pathophysiology of the early phase of asthma:

A

inhalation of allergens -> T1 hypersensitivity reaction immediately
sensitisation occurs during allergen exposure -> release of IgE Abs from plasma cells, which bind to mast cell receptors
subsequent exposure -> degranulation of mast cells and histamine release
->sm contraction, bronchoconstriction
inflammation -> airway obstruction

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14
Q

what is the pathophysiology of the late phase of asthma:

A

the initial early phase followed by:
recruitment of variety of inflammatory cells hours later (PMN cells, T cells)
more complex than early phase
B-agonists do not cause complete reversal

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15
Q

what is the pathophysiology of the chronicity of asthma:

A

response to persistent chronic inflammation
airways lay down fibrous tissue
remodeling occurs -> fixed airway obstruction, narrowing irreversible

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16
Q

what are the typical clinical features of asthma:

A

fine between attacks
sob, exp wheeze, cough
worse at night

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17
Q

what other signs of asthma may be present:

A

prolonged exp phase
tachypnoea
Harrison’s sulcus

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18
Q

what is a Harrison’s sulcus?

A

groove at inferior border of the ribcage seen in children with chronic severe asthma
also rickets

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19
Q

what are the clinical features of a severe asthma attack (acute)?

A

confused mental status
resp effort decreased
hypoxia

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20
Q

how is diagnosis of asthma investigated?

A

spirometry and PEFR

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21
Q

FVC?

A

forced vital capacity - exp

max exp following full insp

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22
Q

FEV1?

A

forced expiratory volume in 1 sec

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23
Q

what spirometry changes seen in obstructive picture?

A

FVC: N or reduced due to air trapping in bases
FEV1: reduced
REV1/FVC ratio: <70%

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24
Q

what is indicative of asthma on spirometry:

A

reversibility when bronchodilators used

12%

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25
Q

how does asthma look on PEFR:

A

variability

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26
Q

step-wise mx of chronic asthma in children:

A 
1. SABA
\+ v. low dose ICS or LTRA if <5
\+LABA or LTRA if <5
\+Low dose ICS or LTRA
\+med dose ICS or theophylline 
\+ oral pred, refer
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27
Q

step-wise mx of chronic asthma in adults:

A 
1. SABA
\+ICS
\+LTRA
\+LABA
\+increase ICS + LAMA/LTRA/theophylline
\+increase ICS +LAMA/LTRA/theophylline+B-ag tablet
\+Oral pred, refer
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28
Q

when should you step up from just SABA tx?

A

if using saba >3x per week

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29
Q

acute mx of asthma attack?

A
  1. Salbutamol, ipratropium nebs, o2 sats>94, steroids
  2. IV Mg sulfate
  3. IV amiophylline, B2 Agonist infusion
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30
Q

identifying life threatening asthma attack in children:

A

silent chest, cyanosis, exhaustion, confusion, poor effort
<92% sats
PEFR<33% predicted for age

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31
Q

identifying life threatening asthma attack in adults:

A

silent chest, cyanosis, echaustion, CONFUSION poor effort
<92% sats
PaO2<8kPa on ABG
PEFR <33% expected
(also acidosis on ABG indicating CO2 retention)

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32
Q

what is Churg-Strauss sydrome?

A

vasculitis affecting the small, medium sized vessels

characterised by late onset asthma, rhinitis, paranasal sinusitis, pulmonary infiltrates

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33
Q

3 phases of Churg-Strauss syndrome?

A
  1. allergic - rhinitis, asthma
  2. eosinophillic - infiltrative disease ->lung/intestine
  3. vasculitic - systemic vasculitis, granulomatous infiltration (renal failure, petechial rash)
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34
Q

65yom presents to GP dyspnoea, wheeze, non-productive cough
no hx atopy
also has low grade fever, malaise, weight loss
raised IgE, CRP, positive p-ANCA?

A

churg-strauss

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35
Q

moa of ipratropium bromide?

A

short acting muscarinic antagonist

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36
Q

moa amiophylline?

A

phosphodiesterase-Inhibitor

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37
Q

MOA adrenaline?

A

alpha-agonist

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38
Q

which antibodies involved in T1 hypersensitivity reaction?

A

IgE

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39
Q

which antibodies involved in T2 hypersensitivity reaction?

A

IgM, IgG

cytotoxic

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40
Q

how is normal airway flow described?

A

laminar flow - ordered flow, quicker in the centre

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41
Q

as the airway divides and becomes narrower, what happens to the air flow?

A

becomes turbulent flow

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42
Q

what is the condition for Pouseuille’s law to apply?

A

laminar flow

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43
Q

what is Pouseuille’s law?

A

Resistance=8xLengthxviscosity/π x radius^4

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44
Q

according to Pouseuille’s law, what happens to the resistance when the radius doubles?

A

airway resistance decreases by 16x

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45
Q

what does bronchomotor tone control?

A

ease with which air is conducted through the airways

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46
Q

what is the rhythm of bronchomotor tone?

A 
follows a circadium rhythm - higher in the mornings
inhaled stimuli (smoke) can increase tone
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47
Q

how do bronchodilators act and what conditions do they treat?

A

they act to reduce the bronchomotor tone

relieve symptoms in COPD and asthma

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48
Q

3 classes of bronchodilator drugs?

A

Beta-2 agonists
muscarinic antagonists
methylxanthines

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49
Q

how many times does the G-coupled protein receptor pass through the cell membrane and what is this called?

A

7 times

7 transmembrane domain

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50
Q

G-coupled protein receptors are metabotropic receptors - what does this mean?

A

their actions are mediated by a secondary messenger (cAMP, DAG)

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51
Q

where are B-2 adrenoreceptors found and which nervous system is affected?

A

primarily the lungs - bronchial smooth muscle

sympathetic

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52
Q

how do B2 agonists work?

A

activate B2 adrenoreceptors in the broncial smooth muscle by the sympathetic NS and cause bronchodilation through smooth muscle relaxation

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53
Q

what are the additional beneficial effects of B2 agonists IN the LUNGS?

A

reduce release of inflammatory mediators from mast cells

increased mucociliary clearance

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54
Q

examples of short and long acting B2 agonists?

what makes them short/ling acting?

A

saba - Salbutamol - hydrophilic - <5mins

laba - salmetarol - lipophilic - 12hrs

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55
Q

what are the adverse effects of B2 agonists?

A

tachycardia - B1/2 adrenoreceptors - heart
arrhythmias - “
tremor - B2 adrenoreceptors skeletal muscle
hypokalaemia - B2 adrenoreceptors Na/K-ATPase channels

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56
Q

what type of receptors are muscarinic receptors?

which nervous system activates them?

A

cholinergic (related to ACh)
metabotropic G-protein coupled receptors
parasympathetic NS

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57
Q

how many subtypes of muscarinic receptor are there and what are the most important ones for bronchodilation?

A

5

M3 (also M1)

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58
Q

how do muscarinic antagonists work?

A

block action of muscarinic ACh receptors - non-selective

relax the smooth muscle in the airways

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59
Q

examples of short and long acting muscarinic antagonists?

A

short - ipratropium

long - tiotropium

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60
Q

adverse effects of muscarinic antagonists?

A

dry mouth - xerostomia
urinary retention
headache
pupillary dilation - exacerbation of glaucoma

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61
Q

what are methylxanthines?

A

nonselective phosphodiesterase inhibitors

cause bronchodilation among other effects

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62
Q

2 examples of methylxanthines?

A

theophylline

amiophylline (IV)

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63
Q

MOA of mexylxanthines?

A

adenosine receptor antagonists

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64
Q

name 4 various effects of methylxanthines?

A

immunomodulation
anti-inflammatory
vasodilation
bronchodilation

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65
Q

what needs to be measured with methylxanthines?

A

toxicity - narrow therapeutic window - 1-1.5

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66
Q

what does methylxanthine toxicity look like:

A 
met - hypokalaemia, hyperglycaemia
CV - hypotension, tachycardia, tachyarrhythmias 
GI - n/v/d
neuro - mood changes, insomnia, seizures
muscle - coarse tremor, rhabdo
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67
Q

advantages of inhaler devices?

A

accurate target of site of action
reduced therapeutic doses
reduced systemic consequences
reduced sfx

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68
Q

disadvantages of inhaler devices?

A

patient education needed

compliance variable-poor

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69
Q

4 types of inhaler device for delivering bronchodilators?

A

MDI - metered-dose inhalers
BAI - breath actuated inhalers
volume spacer
nebuliser - vapourises liquids

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70
Q

define COPD:

A

progressive obstructive airway disease, non-reversible

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71
Q

what does COPD incorporate?

A

disease from airways and parenchyma in the forms of chronic bronchitis and emphysema

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72
Q

aetiology of COPD?

A

smoking most commonly (90%smoking related)

Alpha1-antitrypsin deficiency

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73
Q

what type of emphysema commonly seen in copd?

A

centriacinar (as opposed to panlobular)

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74
Q

what is the inheritance of alpha-1-antitrypsin deficiency and how is it implicated in copd?

A

autosomal codominant
protease inhibitor - acts in lung parenchyma to oppose action of elastase (which breaks down elastin - important for alveoli function) - leads to emphysema

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75
Q

what type of emphysema commonly seen in alpha1antitrypsin deficiency?

A

panlobular with lower zone predominance

higher risk of HCC

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76
Q

pathophysiology of copd generally?

A

disease of both airways and alveoli

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77
Q

what is the pathophysiology of copd in the airways specifically?

A 
chronic bronchitis - inflammation of bronchi - 
goblet cell hyperplasia
mucus hypersecretion 
chronic inflammation and fibrosis
narrowing of small airways
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78
Q

how is chronic bronchitis defined?

A

chronic productive cough for 3+ months on 2 consecutive years where other causes excluded

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79
Q

pathophysiology of copd in alveoli specifically?

A

Inflammatory processes lead to the production of proteases by inflammatory cells such as macrophages. Elastase breaks down elastin, important to the structural integrity of the alveoli.
leads to alveolar collapse, dilation and bullae formation

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80
Q

what is bullae formation?

A

alveoli dilate and join with neighboring alveoli forming bullae

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81
Q

definition of emphysema?

A

permanent enlargement of airspaces distal to the terminal bronchiole when interstitial pneumonias are excluded

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82
Q

what is cor pulmonale?

A

right ventricular HF in response to pulmonary disease

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83
Q

clinical features of copd?

A

cough and dyspnoea hallmarks
also productive cough - white
orthopnoea

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84
Q

signs indicating copd?

A 
dyspnoea
pursed lip breathing
use of accessory muscles 
wheeze
coarse crackles
loss of cardiac dullness
downward displacement of liver
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85
Q

what are signs of co2 retention:

A

drowsy
asterixis
confusion

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86
Q

why does pursed lip breathing help in copd?

A

prevents alveolar collapse by increasing positive end expiratory pressure

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87
Q

signs of cor pulmonale?

A

peripheral oedema
left parasternal heave (right ventricular hypertrophy)
raised JVP
hepatomegaly

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88
Q

what scale is used for categorizing copd?

A

MRC dyspnoea scale (1-N, 5-severe at rest)

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89
Q

what is an acute exacerbation of copd?

A

sustaining worsening of sx that may interrupt patient’s stable course
infective or non-infective

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90
Q

how is the diagnosis and severity of copd best investigated?

A

spirometry - assesses airway obstruction

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91
Q

what will spirometry show in copd?

A

FVC: N or reduced due to air trapping
FEV1: reduced greatly
FEV1:FVC: <70%

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92
Q

how do NICE guidelines stage COPD severity?

A

based on FEV1 as a % of predicted for age
3= FEV1<50%
4=<30%

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93
Q

bedside ix for copd?

A 
obs
BMI
sputum culture if purulent 
pulse ox
ABG - hypoxia/hypercapnia
ECG - cor pulmonale
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94
Q

what may bloods show in COPD?

A

anaemia, polycythaemia on FBC

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95
Q

what will a CXR show in COPD?

A

hyperexpanded
flattened hemidiaphragms
hypodense
saber-sheath trachea

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96
Q

mx of COPD:

A

B2 agonists and Muscarinic antagonists relieve sx

LTOT and smoking cessation decrease mortality

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97
Q

medical mx of copd:

A
  1. SABA/SAMA
    2 (FEV1>50) regular LAMA or LABA
    2 (FEV1<50) regular LAMA or LABA+ICS
  2. regular LABA + LAMA + ICS
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98
Q

who is LTOT reserved for in copd?

A 
when stable have pa02<7.3 (x2)
or pa02<8 +
pulmonary HTN
peripheral oedema
nocturnal hypoxaemia
secondary polycythaemia
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99
Q

how long is LTOT needed for per day?

A

15 hours

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100
Q

what other complimentary therapies can help copd mx?

A

annual flu and one off pneumococcal vaccine

PT

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101
Q

how to treat an acute exacerbation of copd?

A

bronchodilators
pred 30mg for 7-14 days
Abx - tetracyclines (doxy)

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102
Q

which type of respiratory failure are copd patients at risk of getting?

A

T2 hypercapnic

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103
Q

what does T2RF look like on ABG?

A

PaO2<8kPa

PaCo2>6.7kPa

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104
Q

what should target o2 sats be in copd patients?

A

88-92%

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105
Q

what type of masks should be used in copd patients and why?

A

Venturi masks

allow exact FiO2 to be administered (fraction of inspired o2)

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106
Q

What is the predominant inflammatory cell type seen in patients with COPD?

A

neutrophils

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107
Q

what are neutrophils?

A

polymorphonuclear granulocytes essential in the innate immune response

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108
Q

What is the predominant inflammatory cell type seen in patients with asthma?

A

eosinophils

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109
Q

aetiology of lung cancer?

A

smoking
other environmental agents - asbestos
radon gas

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110
Q

what are the 2 categories of lung cancer?

A

small cell

non-small cell (85%)

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111
Q

3 types of non-small cell lung cancer?

A

adenocarcinoma
squamous cell carcinoma
large cell

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112
Q

pathophysiology of adenocarcinoma nsc lung cancer?

A

commonest type, proportionally higher in non-smokers
carcinoma of mucus-secreting cells
occurs in lung peripheries

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113
Q

pathophysiology of squamous cell nsc lung cancer?

A

occurs in central part of lungs
often presents with pneumonia secondary to obstructed bronchus
mets occur late
histology shows keratin

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114
Q

pathophysiology of large cell lung cancer?

A

undifferentiated neoplasms

mets early

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115
Q

pathophysiology of small cell lung cancer?

A

fast doubling time, aggressive nature, early mets
cancer of the APUD cells
exclusively smokers, extremely poor prog
commonly associated with paraneoplastic syndromes

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116
Q

what type of cells are APUD cells?

A

neuroendocrine cells in lungs

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117
Q

clinical features of lung cancer?

A 
commonly asymptomatic 
cough
malaise 
weight loss
haemoptysis
SVC obstruction 
paraneoplastic syndrome
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118
Q

symptoms of lung cancer?

A 
Fever
Malaise
Nausea
Cough
Haemoptysis 
Hoarseness
Weight loss
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119
Q

signs seen in lung cancer?

A 
Lymphadenopathy 
Stridor
Wheeze
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA)
Signs of pleural effusion (exudative)
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120
Q

signs of pleural effusion (exudative):

A

stony dull percussion
reduced vocal fremitus
reduced breath sounds

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121
Q

what is superior vena cava obstruction?

A

when a lung cancer compresses the SVC

causes engorgement of the vessels in the neck and face, sob, and a fullness in the head - swelling

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122
Q

what is a pancoast tumour?

A

tumour of the superior sulcus in the lung
local spread may affect:
brachial plexus
cervical sympathetic trunk and stellate ganglion
subclavian vein

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123
Q

where is the superior sulcus/

A

groove in the first rib

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124
Q

what can pancoast tumours cause?

A

horner’s syndrome
shoulder pain radiating to arm and hand
atrophy of muscles in UL
oedema of UL

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125
Q

where do lung cancers commonly metastasise to?

what are the clinical features of these?

A

bone - pain, raised ALP
brain - focal/non-focal neurology
liver - abnormal LFTs
adrenals - asx

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126
Q

what are paraneoplastic syndromes?

A

remote effects of tumours unrelated to mass effect, invasion or metastasis

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127
Q

name some paraneoplastic syndromes commonly seen in lung cancer?

A 
hypercalcaemia
siadh
cushings - sclc
lambert-eaton syndrome 
hypertrophic osteoarthropathy
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128
Q

why does hypercalcaemia occur in lung cancers?

A

bony mets

tumour secretion of PTHrP, calcitriol

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129
Q

clinical manifestation of hypercalcaemia?

A 
stones, groans, bones, thrones, psychiatric moans 
renal calculi 
bone pain
abdo pain 
polyuria
signs of altered mental status
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130
Q

what is hypertrophic osteoarthropathy?

A

clubbing and periostitis

symmetrical, painful arthropathy of distal joints

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131
Q

urgent referral for lung cancer if:

A

SCVO

stridor

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132
Q

2ww referral lung cancer if :

A

haemoptysis
>40, (ex/)smokers
suggestive cxr
strong clinical suspicion

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133
Q

when to get an urgent cxr in ?lung cancer?

A

suggestive features and history

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134
Q

special tests for lung cancer:

A

tissue biopsy endoscopy
from tumour, lymph node/metastasis

cytology
from aspirates, washings, pleural fluid
from tumour, LN, mets

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135
Q

what staging is used in lung cancer?

A

NSCLC: TNM staging
SCLC: VALSG staging

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136
Q

2 stages of VALSG staging SCLC?

A

limited disease: not beyond hemithorax, regional nodes, 1 RT field
extensive disease: beyond hemithorax, distant mets, malignant effusions, contralateral hilar/subclavicular involvement

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137
Q

management of NSCLC:

A

surgical lobectomy in stage 1/2 +LN sampling
chemo - neo-adjuvant, adjuvant
RT

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138
Q

management of SCLC:

A

surgery - only in very early disease (T1N0M0)
chemo
+ rt (together is mainstay)

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139
Q

2 types of pleural effusion:

A

transudates

exudates (high protein content)

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140
Q

what is a plerual effusion:

A

fluid within the pleural space

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141
Q

exudative causes of pleural effusion are often:

A

infective
inflammatory
malignant

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142
Q

transudative causes pleural effusion are often:

A

secondary to fluid overload or protein loss

CCF, nephrotic syndrome, hypoalbuminaemia

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143
Q

whos criteria is for exudative pleural effusion?

A

Light criteria

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144
Q

what do Light’s criteria state:

A

plerual effusion exudative if:
effusion protein:serum protein >0.5
effusion LDH:serum LDH>0.6
effusion LDH level>2/3 upper limit of the lab’s reference range for normal serum LDH

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145
Q

what is the tidal volume?

A

during normal breathing, the volume of air inspired and expired typically 500ml
over a minute where the RR is 12 this equates to 6L/min

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146
Q

what is the inspiratory reserve volume?

A

additional volume inspired with maximal effort (3L)

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147
Q

what is the expiratory reserve volume?

A

additional volume expired with max effort (1.2L)

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148
Q

what is the residual volume?

A

the volume that remains after the maximal expiration (1.2L)

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149
Q

what is the functional residual capacity?

A

combination of ERV and RV (2.4L)

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150
Q

what is the vital capacity?

A

volume of gas on maximal inspiration and expiration (5L)

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151
Q

what is total lung capacity?

A

total volume of gas in lungs at maximal inspiration

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152
Q

what happens to total lung capacity in obstructive and restrictive disease?

A

obstr - same or increase

restr - reduced TLC

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153
Q

what causes restrictive lung disease?

A

parenchymal, neuromuscular, chest wall diseases

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154
Q

what does peak flow indicate?

A

peak flow rate during the forced expiration following maximal inspiration

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155
Q

when is peak flow highest and lowest in day?

A

afternoon highest

early hours lowest

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156
Q

what does spirometry measue?

A

flow and volume of air, focuses on expiration

fev1, fvc

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157
Q

restrictive lung disease causes - PAINT:

A

intrinsic:
Pleural - pleural effusions, chronic empyema
Alveolar - oedema, haemorrhage
Interstitial - IPF, sarcoid

extrinsic:
Neuromuscular - MG, ALS
Thoracic - kyphoscoliosis, obesity, ascites

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158
Q

what happens to spirometry in restrictive picture:

A

FEV1: reduced
FVC: reduced
FEV1:FVC>0.8

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159
Q

what does a flow-volume loop show:

A

inspiration and expiration on y axis, while flow rate on x axis

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160
Q

pneumonia definition:

A

inflammation of the lung parenchyma

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161
Q

commonest routes of entry for pathogens causing pneumonia:

A

bacteria commonest
inhalation
aspiration
haematogenous

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162
Q

how is pneumonia diagnosed?

A

demonstrating acute consolidation on CXR

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163
Q

what causes consolidation on a CXR?

A

pus in alveoli

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164
Q

how can a CAP be divided?

A

into typical and atypical

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165
Q

commonest cause of a typical cap?

A

s.pneumoniae
hib
moraxella catarrhalis

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166
Q

common features of a typical pneumonia?

A

productive cough
fever
pleuritic chest pain

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167
Q

how do atypical caps usually present?

A

insidious onset

extra-pulmonary sx like malaise, arthralgia and headache, erythema multiforme

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168
Q

commonest causes of atypical pneumonia (cap)?

A

Nonzoonotic - mycoplasma pneumoniae, legionella pneumophila, chlamydophila pneumoniae

zoonotic - chlamydophila pssitaci (pssitocosis), coxiella burnetti (Q fever), francisella tularnsis (tularemia)

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169
Q

definition of a hospital acquired pneumonia?

A

pneumonia acquired >48hrs after admission

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170
Q

likely organisms for HAP:

A

gram negative bacilli: pseudomonas aeruginosa, staph aureus, legionella pneumophila

171
Q

infective organisms causing aspiration pneumonias:

A

streep pneumo, saureus, hib, enterobacteriaceae, klebsiella

172
Q

what is mendelsons syndrome?

A

chemical pneumonitis caused by aspiration of acidic gastric contents classically seen by obstetric anaesthetists

173
Q

infective organisms causing pneumonia in immunocompromised:

A

mycobacterium, non-TB microbacterium
fungal - pneumocystis jirovecci, aspergillus fumigatus, cryptococcus neoformans
viral - varicella, cmv
parasitic

174
Q

how is strep pneumoniae stained for?

A

Gram positive, alpha-haemolytic streptococci

175
Q

what does strep pneumoniae do to blood tests?

A

leucocytosis and raised crp

176
Q

what sputum in strep pneumoniae?

A

rust coloured

177
Q

what is mycoplasma pneumoniae?

A

rod-shaped bacteria that lacks a cell wall

178
Q

what is legionella?

causes?

A

gram negative coccobacillus

cooling systems, humidifiers, showers

179
Q

what electrolyte finding is seen classically in Legionairre’s disease?

A

hyponatraemia secondary to siadh

also hypophosphataemia, raised ferratin

180
Q

what is pseudomonas aeruginosa?

A

gram negative bacillus causing HAP

opportunistic (CF)

181
Q

sputum in p.aeruginosa?

A

green

182
Q

what is klebsiella pneumophila?

who is it commonly seen in?

A

gram negative bacillus

alcoholics

183
Q

sputum in Klebsiella pneumophila?

A

red-current jelly

184
Q

what is pneumocystis jirovecci?

A

fungus, AIDS-defining illness

185
Q

common findings in pneumocystis jirovecci infection?

A

hypoxia, raised LDH

186
Q

treatment of pneumocystis jirovecci?

A

co-trimoxazole (trimethoprim + sulfamethoxazole)

187
Q

signs of pneumonia (clinical findings):

A 
dull percussion note
reduced breath sounds
bronchial breathing 
coarse creps 
increased vocal fremitus 
tachycardia 
hypotension 
confusion 
cyanosis
188
Q

pulmonary complications of pneumonia:

A

parapneumonic effusion
pneumothorax
abscess
empyema

189
Q

extra-pulmonary cx of pneumonia:

A

sepsis

AF

190
Q

what special tests for pneumonia: 1 blood and one other

A

CRP

urinary antigen testing (this does not delay abx)

191
Q

CURB65 stand for?

A 
Confusion
Urea>7
Resp rate >30 
BP <90/60 
age>65 
ON ADMISSION
192
Q

general management measures for pneumonia ?

A

o2 titrated to sats
IV fluids
approproate analgesia

193
Q

in low curb65 scoring CAP - Abx?

A

amoxicillin 5-7 days PO

or doxy/clarithro if pen allergic

194
Q

intermediate severity CAP abx?

A

dual PO therapy amoxicillin + clarithromycin (doxy if pen allergic) 7-10 days

195
Q

high severity cap abx?

A

IV beta-lactamase stable beta-lactam (coamoxiclav)

+ macrolide (clarithro) 7-14/7

196
Q

HAP Abx: mild inf:

A

coamox 625mg TDS

197
Q

HAP Abx: severe:

A

Tazocin (piperacillin/tazobactam) 4.5G TDS

198
Q

what follow up care for pneumonia and why?

A

6/52 CXR - 11% smokers over 50 with pneumonia have lung cancer

199
Q

define sarcoidosis:

A

multisystem granulomatous disorder of unknown aetiology

200
Q

epidemiology of sarcoid:

A

20-50yos

blacks more commonly and worse affected

201
Q

pathophys of sarcoid:

A

not fully understood BUT
immune dysfunction - T cell overactivity
noncaseating granulomas - epithelioid histiocytes

202
Q

manifestation of pulmonary sarcoidosis:

A

interstitial lung disease - fibrosis

203
Q

sarcoid on CXR:

A

bilateral hilar lymphadenopathy

reticular opacitities

204
Q

main symptoms of sarcoid:

A

progressive sob

205
Q

sarcoid sx OE:

A

fine end inspiratory crackles (also seen in IPF)
exertional desaturations
clubbing

206
Q

cx of sarcoid:

A

pulmonary artery HTN

cor pulmonale

207
Q

how does occular sarcoidosis present:

A

uveitis
keratoconjunctivitis sicca
adnexal granulomas
secondary glaucoma

208
Q

what is uveitis:

A

inflammation of the uvea, structure composed of iris, ciliary body and choroid

209
Q

another term for keratoconjunctivitis sicca?

A

dry eye syndrome

210
Q

how does cutaneous sarcoid present?

A

RASHES
papular: head/neck
erythema nodosum: red, painful nodules
lupus pernio: nose, cheeks violaceous nodular

211
Q

other manifestations of sarcoidosis?

A 
hypercalcaemia (calcitriol)
renal disease (nephrocalcinosis) 
CNS disease
Arthralgia
hepatosplenomegaly
bone cysts
cardiac involvement
212
Q

heerfordt’s syndrome:

A 
variant of sarcoid
uveitis
parotid swelling
fever 
facial nerve palsy
213
Q

lofgren’s syndrome:

A 
acute variant of sarcoid
bilat hilar lymphadenopathy 
erythema nodosum
fever
arthralgia
214
Q

spirometry in sarcoid:

A

restrictive pattern

215
Q

why do mantoux test if ?sarcoid?

A

rule out TB - another cause of bilateral hilar lymphadenopathy which causes erythema nodosum

216
Q

blood findings: sarcoid:

A

serum ACE up

217
Q

HRCT of sarcoid:

A

Lymphadenopathy
Diffuse nodularity
Ground glass opacification
Fibrosis typically affecting the upper lobes

218
Q

Brochoalveolar lavage ± transbronchial biopsy:

sarcoid

A

inversion of CD4/CD8 ratio
raised lymphocytes
biopsy showing non-caseating granuloma

219
Q

staging in sarcoid:

A 
based on cxr
0 - N
1 - bilat hilar lymphadenopathy
2 - +infiltrates
3 - infiltrates alone
4 - pulmonary fibrosis
220
Q

who gets tx in sarcoid:

A

symptomatic or stage 4

221
Q

what is tx in sarcoid:

A

pred 20-40mg/day

lung transplant if end stage

222
Q

upper lobe fibrosis: causes - breast

A 
Bronchopulmonary aspergillus
RT
Extrinsic allergic alveotlitis 
Ankylosing spondylitis 
Sarcoid
TB
223
Q

lower lobe fibrosis causes: CRABS

A 
cryptogenic fibrosing alveolitis (IPF)
RA
Asbesosis 
Bleomycin 
SLE, scleroderma
224
Q

causes of erythema nodosum:

DIPS OUT

A 
Drugs (sulfonamides)
Infection (strep)
Pregnancy
Sarcoid
Oral contraceptive pill
UC (IBD)
TB
225
Q

causes of ILD:

A 
Idiopathic pulmonary fibrosis
Granulomatous (e.g. sarcoidosis)
AI and collagen vascular disorders (e.g. rheumatoid)
Inorganic (e.g. pneumoconiosis)
Organic (e.g. farmers lung)
Infective (e.g. tuberculosis)
Drugs (e.g. amiodarone)
226
Q

side effects of steroid use:

cushingoid

A 
C - Cushing’s syndrome/cataracts
U - ulcers (stomach)
S - skin thinning/striae
H - hypertension/hirsutism
I - infections
N - necrosis (avascular necrosis of the femoral head)
G - glycosuria
O - osteopaenia/osteoporosis
I - immunosuppression
D - diabetes
227
Q

what causes TB and how does it spread?

A

mycobacterium tb/bovis/africanum/microti

respiratory droplets

228
Q

how is multi-drug resistant TB being combatted?

A

multiple drug regimens and also a directly observed therapy (DOT) for adherence

229
Q

3 features of microbacterium:

A
  • obligate aerobes - require o2
  • facultative intracellular - prefer to be intracellular
  • acid fast bacilli - resistance to decolouriztion by staining by acid
230
Q

In post-primary TB, what are the common manifestations?

A

Pulmonary TB 55%

Extra-pulmonary TB 45%

231
Q

pathophys TB:

A

inhaled bacilli divide in alveoli - primary TB
host immune response
alveolar macrophages phagocytose bacilli
Ghon complex may develop -> Ranke complex

232
Q

what is a ghon complex?

A

TB pathognomonic lesion seen in children where:

  • Ghon focus (small caseating granuloma)
  • lymphadenitis
  • lymphangitis
233
Q

what is a ranke complex?

A

a healed ghon complex seen in latent TB

234
Q

what is Milliary TB:

A

haematogenous spread of TB

millet seeds on cxr - CNS involvement 20%

235
Q

clinical triad of TB: pulm

A

fever
weight loss
cough

also sob, haemoptysis

236
Q

how does Lymph Node TB appear:

A

firm, non-tender, enlarged

commonly cervical, supraclavicular

237
Q

how does CNS TB present?

A

TB meningitis

fever, malaise, headache

238
Q

what does CSF look like in TB meningitis?

A

high protein
low glucose
lymphocytosis

239
Q

what is Pott’s syndrome?

A

TB in vertebrae

fever, weight loss, back pain

240
Q

what does Adrenal TB commonly cause?

A

leading cause of Addison’s disease worldwide

241
Q

diagnosis of latent TB:

A

mentoux test- IV hypersensitivity reaction +

Intraferon gamma release assay

242
Q

diagnosis of active TB:

A

stains - acid fast bacilli - auramine O (Ziehl-Neelson)
cultures
PCR

243
Q

what type of cultures id active TB?

A

Lowenstein-Jensen

4-6 weeks to get result

244
Q

vaccine for TB? what needs doing first?

A

BCG

mantoux first

245
Q

what type of vaccine is the TB vaccine? what does it also protect against?

A

live attenuated
leprocy
also treats bladder ca

246
Q

ABx for TB? RIPE

A

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

247
Q

side effects of TB abx:

A

R - LFTs, secretions pink, COCP null
I - polyneuropathy
P - hepatotoxic, gout
E- ON

248
Q

who gets treated for latent TB:

A 
adults <35 OR
HIV+ OR
healthcare workers
AND
mantoux test + >6mm - BCG
CXR 
at risk groups
249
Q

how long are doses of abx in latent TB?

A

6I

or 3RI

250
Q

how long doses of abx given in active pulm TB?

A

(2HRZE, 4HR

251
Q

how long doses abx given in pereicardial TB:

A

same as pulm TB but + pred

252
Q

how is active CNS TB mx:

A

2HRZE, 10HR

pred

253
Q

what is bronchiectasis?

A

permanent dilation of airways caused by chronic inflammation and inability to clear secretions

254
Q

what are causes of bronchiectasis (congen/acquired)

A

congen:
CF
Young’s syndrome, Kartagener’s syndrome

acquired: post-infective
tumours
RA
IBD

255
Q

what will CXR of bronchiectasis show?

A

tram track opacities of bronchi and bronchioles

256
Q

what is pneumoconiosis?

A

disease of lungs due to inhalation of dust, characterised by inflammation, cough, fibrosis

257
Q

where are the 3 respiratory centres in the brain?

A

pons respiratory centre
medullary respiratory centre
pre-Botzinger complex

258
Q

which respiratory centre affects respiratory rhythm?

A

pre-Botzinger complex

exhibits pace-maker like activity on the medullary centre

259
Q

where are the central chemoreceptors located?

A

ventrolateral surface of medulla

260
Q

what are the central chemoreceptors sensitive to and what do they stimulate?

A

pH of the CSF - Co2 (NOT H+) can cross BBB (lipid sol)

stimulates/inhibits ventilation

261
Q

how does a reduction in CSF pH affect ventilation?

A

increase in Co2 - increase in ventilation

262
Q

where are peripheral chemoreceptors found?

A

carotid bodies - bifurcation - ph, o2, co2

aortic bodies - aortic arch - respond to o2, co2

263
Q

which is more responsible to response of ventilation to raised co2 in blood - peripheral or central and which is faster response?

A

80% central - slower response

20% peripheral - faster response

264
Q

define respiratory failure:

A

inadequate gas exchange in the lungs

265
Q

what causes o2-induced hypercapnia, and what does not cause this?

A

caused by V/Q mismatch, hypoxic pulmonary vasoconstriction
Haldane effect

NOT desensitisation of resp centre to raised co2

266
Q

what are o2-induced hypercapnic patients referred to as?

how are they managed?

A 
chronic retainers (of co2)
target o2 sats of 88-92%
267
Q

what is the Haldane effect?

A

Hb increases its ability to carry co2 when deoxygenated

268
Q

what is the Bohr effect?

A

Hb’s o2 affinity falls under acidic conditions

269
Q

what is the diver’s reflex?

A

bradycardia, suppression of ventilatory drive and redirection of oxygenated blood to brain

270
Q

Hering-Breuer lung inflation reflex:

A

inhibition of inspiration due to stimulation of stretch receptors on max inspiration

271
Q

different types of pneumoconiosis:

A 
coal miners pneumoconiosis 
bauxite fibrosis
berylliosis
asbestosis
siderosis (iron)
silicosis
272
Q

what is a PE?

A

occlusion of pulmonary vasculature by a clot

273
Q

causes of PE:

A 
DVT
air embolus
fat embolus
amniotic fluid embolus 
IVDU
274
Q

what is a penumothorax?

A

air within the pleural space

275
Q

causes of pneumothorax:

A 
ruptured pleural bleb 
COPD
TB
sarcoid
IPF
RA
Ank spond
Lung cancer
trauma
asthma
-> ADMIT any secondary pneumothorax
276
Q

severe adult asthma attack mx?

A

nebulised salbutamol
Nebulised ipratropium bromide (given to all sev+Lifethreat)
PO Pred

277
Q

patients with COPD who have had >3 exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year. Prophylaxis with which drug should be considered????

A

azithromycin 6-12months

278
Q

45-year-old man is prescribed bupropion to help him quit smoking. What is the mechanism of action of bupropion?

A

norepinephrine and dopamine reuptake inhibitor and nicotinic antagonist
(CI in epilepsy)

279
Q

chest x-ray shows clear widenening of the mediastinum - ddx?

A

goitre, lymphoma and thoracic aneurysm may cause this finding
Lymphoma if night sweats

280
Q

heart failure CXR:

A

Alveolar oedema (bat’s wings), Kerley B lines (interstitial oedema), Cardiomegaly, Dilated prominent upper lobe vessels, Effusion (pleural) are features of heart failure on a chest x-ray

281
Q

deviated trachea on CXR indicates?

A

tension pneumothorax

282
Q

AECOPD - started on amoxicillin and prednisolone by his GP. Since arriving in the department he has been given back-to-back nebulised salbutamol and ipratropium bromide. The oxygen concentration has been titrated to 28% to achieve a saturation of 88-92%. Due to his poor response to treatment an aminophyline infusion is started. next tx?

A

NIV

283
Q

commonest org to cause AECOPD?

A

Hib

284
Q

who do NICE recommend giving abx to in AECOPD?

A

if sputum purulent or clinical sx of pneumonia only

not all patients

285
Q

AECOPD infective definition:

A

increasing dyspnoea, cough, wheeze
increase in purulent sputum
increase in hypoxia +- confusion

286
Q

treatment of extrinsic allergic alveolitis?

A

avoidance of triggers

287
Q

tx for sinusitis?

A

not abx in uncomplicated cases

288
Q

patients with COPD who are dx with pneumonia tx:

A

Abx and steroids - even if no evidence of exacerbation

289
Q

48-year-old male presents with a 8 week history of epistaxis and nasal stuffiness. On examination there is evidence of nasal crusting. A chest x-ray demonstrates multiple cavitary lesions. which antibodies are you ix for?

A

ANCA (c)

granulomatosis with polyangiitis (Wegners)

290
Q

which organism most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics?

A

klebsiella

291
Q

patient with a background of COPD presents to the emergency department with a simple pneumothorax 2.2 cm in size. What is the most suitable management option?

A

chest drain

292
Q

criteria for tx pneumothoracies:

A

1-2cm - aspirate first line
>2cm+SOB chest drain
<2cm without SOB - Discharge

stop smoking advice

293
Q

which side is aspiration pneumonia more common on?

A

right lung
due to the larger calibre and more vertical orientation of the right main bronchus.
common in recently ET intubated people

294
Q

Other than findings on respiratory examination, which observation makes the diagnosis of tension pneumothorax more likely than simple pneumothorax?

A

hypotension in tension pneumo due to low cardiac outflow (obsructed)

295
Q

sign guidelines of escalating asthma mx:

A
  1. Oxygen
  2. Salbutamol nebulisers
  3. Ipratropium bromide nebulisers
  4. Hydrocortisone IV OR Oral Prednisolone
  5. Magnesium Sulfate IV
  6. Aminophylline/ IV salbutamol
296
Q

The general signs of lobar collapse on a chest x-ray are as follows:

A

tracheal deviation towards the side of the collapse
mediastinal shift towards the side of the collapse
elevation of the hemidiaphragm

297
Q

ARDS definition:

A

characterised by bilateral pulmonary infiltrates (“alveolar shadowing”) and hypoxaemia

298
Q

71-year-old patient with a 2-month history of a cough and associated weight loss shows a suspicious lung mass on chest X-ray. Which of the following is the most appropriate next step?

A

contrast enhanced CT

299
Q

his oxygen saturations are 60% on room air. He is in the tripod position and using his accessory muscles to breathe. His lips have a blue tinge to them. You note that he has been admitted to hospital several months ago and that he is known to retain CO2.

Which of the following methods of oxygen delivery would be most suitable

A

15L non-rebreathe

300
Q

well controlled asthma on salbutamol (never used) and BD steroids - mx??

A

50% step down in steroid use then rv in 6months

301
Q

What are the boundaries of the ‘safe triangle’ for chest drain insertion?

A

Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.

302
Q

type II respiratory failure. You are asked to consider non-invasive ventilation. At what pH is the patient most likely to receive benefit from non-invasive ventilation?

A

7.25-7.35 achieve the most benefit. If the pH is < 7.25 then invasive ventilation should be considered if appropriate

303
Q

dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)

these describe which inherited condition?

A

Kartagener’s syndrome

304
Q

kartagener syndrome pathology?

A

dynein arm defect results in immotile cilia

305
Q

Benign ovarian tumour, ascites, and pleural effusion. this indicates which dx?

A

Meig’s syndrome

306
Q

what is the most common cause of an exudative pleural effusion?

A

pneumonia

307
Q

what type of pleural effision when ethe protein level >35 and the LDH >200??

A

exudative

308
Q

causes of transudative effusion?

A

heart failure
renal failure (hypoalbuminaemia)
hypothyroidism
meig’s syndrome

309
Q

causes of exudative effusion?

A
  • infection: pneumonia (most common exudate cause), TB, subphrenic abscess
  • connective tissue disease: RA, SLE
  • neoplasia: lung cancer, mesothelioma, metastases
  • pancreatitis
  • pulmonary embolism
  • Dressler’s syndrome
  • yellow nail syndrome
310
Q

definition of exudative and transudative effusion?

A

exudative >30g/L protein

transudative <30g/L protein

311
Q

dullness to percussion, reduced breath sounds and reduced chest expansion are all examination findings pointing towards????

A

pleural effusion

312
Q

oedema signs on CXR:

A

lines! Kerley A lines, Kerley B lines and Kerley C lines represent expansion of the interstitial space by fluid.

313
Q

55-yom -> GP 7/7 general fever and malaise, and a 2/7 non-productive cough. His eyes have also been sticky and sore for the last few days. appears visibly unwell, with a fever of 38.2ºC, RR 20. mild splenomegaly.

no hx recent travel and denies tuberculosis exposure/contact. He is, however, the proud new owner of George, a red-crested Australian King Parrot, who he has had for a month.

What is the most likely cause of this gentleman’s symptoms?

A

chlamydia psittaci

domesticated and exotic birds. C. psittaci classically causes a respiratory infection as well as an acute or chronic conjunctivitis

314
Q

which lung ca is commonly associated with gynaecomastia, hypertrophic pulmonary osteoarthropathy (HPOA) and non-smokers????

A

adenocarcinoma

315
Q

ambert-Eaton syndrome and syndrome of inappropriate anti-diuretic hormone (SIADH) secretion in which type of lung ca

A

small cell!

316
Q

which lung ca associated with HPOA, parathyroid hormone-related protein secretion causing hypercalcaemia, and hyperthyroidism due to ectopic thyroid stimulating hormone secretion.??

A

squamous cell ca

smokers

317
Q

pathology of hoarseness in lung ca?

A

seen with Pancoast tumours pressing on the recurrent laryngeal nerve - ix CT chest

318
Q

Indications for corticosteroid treatment for sarcoidosis are:

A

parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement

319
Q

Nasogastric tubes are safe to use if pH?

A

<5.5 on aspirate

320
Q

if NG tube aspirate >5.5 - what do ya do?

A

CXR to look at placement of tube

321
Q

inhaler technique advice:

A

after inhaling, hold breath for 10 seconds

second dose 30 seconds after the first

322
Q

A 72-year-old gentleman presents to the respiratory clinic with worsening shortness of breath. On examination, he has obvious thoracic kyphosis. Assuming that this is the only cause of his breathlessness, which pulmonary function test results would you expect to see?

A

FEV1:FVC 85%, reduced gas transfer (TLCO) and increased KCO (transfer coefficient)
Extrapulmonary restrictive defect

323
Q

KCO also tends to increase with age. Some conditions may cause an increased KCO with a normal or reduced TLCO:

A

pneumonectomy/lobectomy
scoliosis/kyphosis
neuromuscular weakness
ankylosis of costovertebral joints e.g. ankylosing spondylitis

324
Q

COPD - still breathless despite using SABA/SAMA and a LABA + ICS → mx?

A

tiotropium prescription
add a LAMA
(use combination inhalers where poss to increase complaince)

325
Q

what indicated in respiratory acidosis or rising PaCO2 resistant to best medical management during an acute exacerbation of COPD?

A

bipap (Niv)

326
Q

Acute respiratory distress syndrome can only be diagnosed in the absence of a???

A

cardiac cause for pulmonary oedema (pulmonary capillary wedge pressure should not be above 15)

327
Q

TRALI definition?

A

transfusion related acute lung injury - ARDS occurring within 6 hours of a transfusion taking place

328
Q

normal chest x-ray an ex-smoker with shortness of breath, weight loss and hyponatraemia should be investigated???

A

for lung cancer - urgent referral to chest clinic

329
Q

most effective mx to slow decrease of fev1 down in copd?

A

stop smoking

330
Q

what tx should be given in a CAP on background of COPD even if no evidence of AECOPD?

A

pred

331
Q

x-ray shows a large right sided hilar mass with resultant collapse of the right upper lobe. As a consequence the hyperexpanded right middle and lower lobes are hyperlucent (‘blacker’). in a 79M dx?

A

lung ca

332
Q

A 52-year-old man who was born in India presents with episodic haemoptysis. His only history is tuberculosis as an adolescent. Chest x-ray shows a rounded opacity in the right upper zone surrounded by a rim of air.
dx?

A

aspergilloma

in hx of TB and round opacity on XR

333
Q

A 71-year-old woman presents with dyspnoea and haemoptysis for the past two weeks. Clinical examination reveals a loud first heart sound, a diastolic murmur and new-onset atrial fibrillation.
dx?

A

mitral stenosis

haemoptysis secondary to rupture of the bronchial veins caused by raised left atrial pressure.

334
Q

A 62-year-old woman who is being investigated for renal impairment presents with haemoptysis. On examination she has a flat nose.
dx?

A

granulomatosis with polyangitis

classic triad saddle nose, pulm haemorrhage, renal impairment

335
Q

Scale is used in the identification of obstructive sleep apnoea????

A

epworth sleepiness scale for OSA

336
Q

obstructive sleep apnoea risk factors:

4

A

obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome

337
Q

cx of OSA:

A

daytime somnolence
compensated respiratory acidosis
hypertension

338
Q

dx test and mx of OSA:

A

sleep studies - polysonmography

CPAP if respiratory acidosis (first line for osa after weight loss)

339
Q

OD on which substance associated with respiratory alkylosis?

A

salicylate

340
Q

respiratory alkalosis ddx:

5

A 
anxiety leading to hyperventilation
pulmonary embolism
salicylate poisoning*
CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
altitude
pregnancy
341
Q

When managing patients with COPD, once the pCO2 is known to be normal the target oxygen saturations should be???

A

94-98%

342
Q

prevention of high altitude cerebral oedema medicine?

A

Acetazolamide

343
Q

treatment of high altitude cerebral oedema medicine?

A

dex

344
Q

chest x-ray shows a right basal opacity obscuring the right costodiaphragmatic recess with a meniscus, findings consistent with?

A

pleural effusion

345
Q

COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features →????

A

add laba+lama

346
Q

what is recommended to start early in the course of COPD, as soon as patients start feeling shortness of breath with regular activity??

A

pulmonary rehabilitation

347
Q

mx tension pneumothorax?

A

blunt cannula 14G (no CXR first - emergent) into 2nd intercostal space

348
Q

after 1 PE, what makes the risk the greatest that they will have another PE in future?

A

if the first PE was unprovoked

349
Q

24F episodic wheezing and shortness of breath for the past 4 months. She has smoked for the past 8 years and has a history of eczema. Examination of her chest is unremarkable. Spirometry is arranged and is reported as normal.
What is the most appropriate next steps?

A

FeNO test and spirometry with bronchodilator reversibility

350
Q

Reversibility testing in adults, a positive test is indicated by an improvement in FEV1 of :

A

> 12% and >200ml volume increase

351
Q

28-year-old man is in the surgical intensive care unit. He has suffered a flail chest injury several hours earlier and he was intubated and ventilated. Over the past few minutes he has become increasingly hypoxic and is now needing increased ventilation pressures. What is the most common cause?

A

tension pneumothorax in flail chest

352
Q

56-yM -> ED with pleuritic chest pain, dyspnoea and pyrexia. PMH alcohol abuse and he smells strongly of alcohol. Starts coughing currant jelly sputum. You admit him and prescribe the appropriate antibiotics. You culture the sputum and the causative agent has been identified. Which other condition is associated with this organism too?

A

pleural empyema

klebsiella common in alcoholics

353
Q

massive pleural effusion identification on CXR and mx?

A

meniscal line sueprio-lateral aspect, midline shift
pleural aspiration
trachea deviation away from side with effusion

354
Q

COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features →

A

+LABA + ICS

355
Q

In primary pneumothorax that has either shortness of breath or >2cm rim of air, mx

A

aspiration

356
Q

COPD - still breathless despite using SABA/SAMA and a LABA + ICS →

A

add a LAMA (tiotropium)

357
Q

Lower zones lung fibrosis: caused by which drug?

A

amiodarone

358
Q

Before starting azithromycin do which ix?

A

ECG - r/o long QT (also CI in clari)

and baseline LFTs

359
Q

can dx of COPD given if FEV1>80%?

A

yes if symptomatic of COPD and FEV1:FVC<0.7

360
Q

DKA: metabolic acidosis with _______ anion gap?

A

raised

361
Q

if moderate acute asthma attack, what feature of PMH would prompt admission?

A

previous near fatal attack

362
Q

If a pleural effusion is drained too quickly, a rare but important complication that can develop is?

A

re-expansion pulmonary oedema

363
Q

A 33-year-old woman is prescribed varenicline to help her quit smoking. What is the mechanism of action of varenicline?

A

nicotinic receptor partial agonist

364
Q

if ? asthma what will response to aspirin be?

A

poor - will make sx worse

365
Q

indications for surgery in bronchiectasis?

A 
localsied disease (1 lobe)
uncontrollable haemoptysis
366
Q

COPD symptoms in a young person - think of which disease?

A

alpha-1-antitrypsin deficiency (A1AT)

could be a misdiagnosis of asthma too

367
Q

Turbid effusion with pH<7.2, Low glucose, High LDH - dx?

A

empyema

368
Q

all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment should get?

A

NIV (BiPAP)

369
Q

64-M develops difficult breathing 15 hours post-emergency laparotomy. Fine crackles are heard on the right lower zone, and there is resonance on percussion. sats 96% on air, hr 78, respiratory rate is 16 , bp 110/68, and the temperature 38.1 ºC. A chest X-ray reveals a small area of airway collapse in the right lower lobe. dx, mx?

A

atelectasis
chest physio and breathing exercises
ix - cxr

370
Q

resp causes of clubbing:

A 
lung cancer
pyogenic conditions: cystic fibrosis, bronchiectasis, abscess, empyema
tuberculosis
asbestosis, mesothelioma
fibrosing alveolitis
idiopathic pulmonary fibrosis
371
Q

52-M 5/7 hx cough, feeling hot and facial pains. He is generally fit and well. DH: sertraline for anxiety and depression. He describes a cough productive of pale yellow sputum. He also describes difficulty breathing through his nose and pain in his face, particularly when coughing on leaning forward.
On examination he is alert, pulse rate is 84/min, temperature is 37.3º and respiratory rate is 16/min. His blood pressure is 122/74 mmHg. Chest auscultation is unremarkable. He is tender over the maxilla. dx?

A

viral URTI

372
Q

progressive asbestos changes lungs:

A

pleural plaques - benign
pleural thickening
asbestosis
mesothelioma

373
Q

Indications for corticosteroid treatment for sarcoidosis are:

A

parenchymal lung disease
uveitis
hypercalcemia
neuro/cardiac involvement

374
Q 
asbestos:
which lobes affected?
most dangerous form?
severity related to?
can you get mesothelioma with limited exposure?
A

lower lobes
blue crocidolite asbestosis
related to length of exposure
yes

375
Q

mesothelioma diagnosis confirmed by?

A

histology following biopsy from thoracoscopy

376
Q

heroin addict ABG?

A

respiratory acidosis due to hypoventilation

377
Q

67M progressive exertional dyspnoea. These symptoms have been getting progressively worse over the past nine months and are associated with a dry cough. He gave up smoking 20 cigarettes/day around 30 years ago. On examination his oxygen saturations are 97% on room air, respiratory rate is 14/min and there are some fine bibasal crackles. Finger clubbing is noted. dx?

A

idiopathic pulmonary fibrosis

note in history: exertional

378
Q

allergic bronchopulmonary aspergillosis (ABPA) in CF patient. First-line tx?

A

Prednisolone

Itraconazole 2nd line

379
Q

obstructive picture with normal/raised total gas transfer (TLCO) with raised transfer coefficient (KCO): causes: (2)

A

asthma

pulmonary haemorrhage

380
Q

Sudden deterioration with ventilation suggests which condition?

A

tension pneumothorax

381
Q

28-M. trying for children for the last 2 years. His wife has had 2 children already. PMH: repeated chest infections and repeated bouts of otitis media. frequent URTIs requiring abx. This is an ongoing problem since childhood. He believes that there is something wrong his genital tract. His right testicle hangs lower than his left. Apex beat is in the 5th intercostal space on the right midclavicular line. dx?

A

kartageners syndrome

primary ciliary dyskinesia

382
Q

58-F -> GP 5/7 hx mild SOB with exertion. Associated cough and productive sputum 3/7 ago. Prior to this, she had a runny nose, mild headaches and generalised muscle fatigue. No fever, chills or rigour. BG: of poorly-controlled COPD and T2DM, in which she is currently taking salbutamol puffers as required, regular metformin and insulin.
Grandson had a fever and purulent cough, and an associated exanthematous rash 2/52 ago which had resolved spontaneously. She does not smoke and drinks 2 standard drinks a day.
Appears well and rested. Obs are stable. Bilateral scattered wheeze bibasally and no increase in vocal resonance. next step in management?

A 
po amoxicillin 
(doxy if allergic)

in bronchitis if co-morbidities, tx with abx

383
Q

chest x-ray shows multiple nodular opacities in the upper lobes which are commonly seen in a restrictive spirometry picture - dx?

A

pneumoconiasis

384
Q

on cxr: The loss of the left heart border is a classic sign of???

A

left lingula consolidation

385
Q

(FEV1:FVC >70%, decreased FVC) and impaired gas exchange (reduced TLCO, KCO) - dx?

A

idiopathic pulmonary fibrosis

386
Q

asbestosis spirometry?

A

restrictive

387
Q

cannonball mets - think which ca?

A

RCC - ix CT abdo

388
Q

lung ca hx with Difficulty walking and muscle tenderness?

A

LEMS features -> small cell

389
Q

secondary pneumothorax 1-2cm without breathlessness - mx?

A

aspiration

390
Q

which RA drug most likely caused Bilateral interstitial shadowing on CXR?

A

MTX

391
Q

pneurmonia vs bronchitis - how to differentiate ?

A

pneumonia = SOB, obs would be off, would have focal examination sx, sputum, wheeze

392
Q

Bronchiectasis: most common organism =

A

hib

green sputum

393
Q

Asthmatic features/features suggesting steroid responsiveness in COPD:

A

previous diagnosis of asthma or atopy
a higher blood eosinophil count
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)

394
Q

A normal PaCO2 in an acute asthma attack indicates???

A

exhaustion and should therefore be classed as life-threatening asthma -> ITU

395
Q

Alpha1-antitrypsin deficiency can be diagnosed prenatally using???

A

chronic villus sampling 11-14/40

amniocentesis - 15-20/40

396
Q

surgical treatment of alpha-1 antitrypsin deficiency?

A

lung volume reduction surgery

397
Q

chest drain swinging = ?

A

water seal rising on inspiration and falling on expiration

398
Q

commonest causes of an anterior mediastinum mass can be remembered by the 4 T’s:

A

Teratoma
terrible lymphadenopathy
thymic mass
thyroid mass

399
Q

30-F->ED 2/12 hx diplopia. Increasing fatigue and weakness, especially at the end of the day. She is found to have anti-acetylcholine receptor antibodies. CT chest: anterior mediastinal mass.
What is this anterior mediastinal mass most likely to be?

A

thymoma -> MG

400
Q

30M PMH asthma presents with a 5/7 hx cough and wheeze. He currently takes salbutamol prn and beclometasone 200mcg bd. His peak flow is 70% of normal. tx?

A

5 day course PO Pred

steroids in all acute cases of asthma

401
Q

The features of acute severe asthma are:

A

PEFR 33-50% best or predicted, inability to complete full sentences, RR >25/min and pulse >110 bpm

402
Q

71M being investigated for recurrent collapse during exertion presents with progressive shortness of breath. His pulse is 84 / min and blood pressure 110/90 mmHg. dx?

A

aortic stenosis

403
Q

Pt has hx recurrent pulmonary embolism despite anticoagulation with warfarin. Changes would be expected on spirometry?

A

reduced TLCO

404
Q

caused raised TLCO:

A 
asthma
pulmonary haemorrhage (Wegener's, Goodpasture's)
left-to-right cardiac shunts
polycythaemia
hyperkinetic states
male gender, exercise
405
Q

causes reduced TLCO:

A 
pulmonary fibrosis
pneumonia
pulmonary emboli
pulmonary oedema
emphysema
anaemia
low cardiac output
406
Q

Pregnant women who smoke: cessation options:

A

Nicotine replacement patches

varenicline and bupropion are contraindicated

407
Q

diagnostic ix for IPF?

A

high-resolution CT

408
Q

A 24-year-old female presents with facial weakness, fever and painful red eyes. On examination you note a left sided facial palsy and tender swelling of the parotid glands. Laboratory results reveal a calcium level of 2.82 mmol/L. dx?

A

sarcoid

hypercalcaemia seen

409
Q

is prednisolone safe to take while breastfeeding after acute asthma attack?

A

yes

all asthma drugs safe to continue in preg too

410
Q

45f-> GP with a new rash on her face. Raised purple lesion covering the nose, cheeks and lips. Dx rosacea however it has rapidly progressed. Also notes axillary and inguinal lymphadenopathy. Fatigue as well as some dyspnoea over the last 6 months. She has smoked 10 cigarettes a day for the last 8 months and drinks 10 units of alcohol a week. dx?

A

sarcoid

411
Q

what will CRP and WCC do in treatment of acute bacterial infection (eg CAP)

A

CRP lags behind the WCC so if clinically improving but crp increases could be a lag

412
Q

CI for chest drain?

A

INR>1.3
plts<75
bullae, adhesions

413
Q

lung nodules in the context of rheumatoid arthritis (RA) - which syndrome?

A

caplan

414
Q

70M->ED 1/52 worsening dyspnoea. 50 pack-years. No hx trauma, fever, productive cough, or weight loss.
Hyper resonance and reduced breath sounds on the upper right hand side. CXR large lucent areas over the right lung without a visible wall. Chest tube was inserted under the presumed diagnosis of a spontaneous pneumothorax. No symptomatic relief. Follow-up CXR reveals no improved expansion of the right lung. dx?

A

large bullae in COPD can mimic pneumothorax

415
Q

42-M->ED acute severe asthma. Beta-agonist by nebuliser, and oral steroids. After a few hours
his asthma is better but he develops weakness in both legs and finds he is unable to get up from his chair. why?

A

hypokalaemia due to salbutamol

416
Q

noc CF bronchiectasis mx?

A

Symptom control in non-CF bronchiectasis - inspiratory muscle training + postural drainage

417
Q

ipratropim??

A

SAMA

418
Q

25F 2/7 hx sob. pain in both knees as well as alopecia and oral ulcers. Rash on the cheeks and nose is observed. Dull percussion notes and diminished breath sounds are noted in both lower lung fields. A chest radiograph demonstrates bilateral pleural effusion. ix, dx?

A

ANA

SLE

419
Q

pleural fluid aspiration is performed. The appearance of the fluid is clear and is sent off for culture. Whilst awaiting the culture results, which one of the following is the most important factor when determining whether a chest tube is placed?

A

pH

420
Q

Contraindications to lung cancer surgery include ??

A

SVCO
FEV<1.5
malignant pleural effusion
vocal cord paralysis

421
Q

British Thoracic Society suggest X is a factor making asthma less likely?

A

peripheral tingling when sob

422
Q

1st line for acute bronchitis?

A

doxy

423
Q

which arrhythmia can be caused by tension pneumothorax?

A

PEA- reversible

3b/4 (19 decks)

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