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Phase 3b > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Tools for measuring breathlessness?

A

NYHA Class
MRC breathlessness scale
WHO classification

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2
Q

Which patients would you want to keep below normal oxygen sats? What sats would you want in these?

A

Those at risk of hypercapnic respiratory failure ( those with chronic type 2 respiratory failure - e.g. severe COPD or nocturnal paroxysmal dyspnoea)

88-92%

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3
Q

Respiratory microbiology tests you can do

A 
AFB 
Blood culture 
Pneumococcal antigen 
Legionella antigen (urine)
PCR (mycoplasma, chlamydia)
Procalcitonin (distinguishes between bacterial and viral - if low avoid abx)
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4
Q

Narcolepsy treatment

A

Daytime: Modafinil (stimulant)

Nighttime: Sodium Oxybate (powerful sedative)

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5
Q

Management of small cell lung cancer

A

Largely chemo and radiotherapy - surgery not appropriate

Surgery if T1-2a, N0, M0

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6
Q

Which lung cancer is proportionately more prevalent in non-smokers?

A

Adenocarcinoma (NSCLC)

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7
Q

Most common form of lung cancer, and where does it appear in the lung?

A

Adenocarcinoma

In lung peripheries in mucus-secreting cells

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8
Q

Where does squamous cell carcinoma usually appear and how does it present?

A

Central part of lung

Can present with pneumonia secondary to an obstructed bronchus

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9
Q

What is hypertrophic pulmonary osteoarthropathy (HPOA)?

A

TRIAD:
Periostitis
Arthropathy of large joints
Digital clubbing

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10
Q

What structures can a pancoast tumour compress, and thus what effects might it have?

A

Subclavian vein
Cervical sympathetic trunk
Brachial plexus

Effects:
Horner’s syndrome
Shoulder pain that radiates to arm and hand
Atrophy of muscles and oedema of upper limb

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11
Q

Paraneoplastic syndromes that may occur in lung cancer

A

Hypercalcaemia

SIADH (cerebral oedema, hyponatraemia)

Hypertrophic pulmonary osteoarthropathy

Cushing’s syndrome (ACTH production)

Lambert-Eaton syndrome (antibodies to voltage gated calcium channels –> proximal and ocular muscle weakness)

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12
Q

When would you send a patient for an urgent referral or 2 week wait under suspicion of lung cancer?

A

Urgent: SVCO or stridor

2 week wait: CXR suggestive, unexplained haemoptysis >40

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13
Q

When would you consider an urgent CXR for lung cancer in patients over 40?

A 
Lymphadenopathy
Clubbing 
Thrombocytosis 
Chest signs 
Recurrent chest infections

2 of: appetite loss, weight loss, smoking/asbestos hx, cough, fatigue, SOB, chest pain

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14
Q

Possible diagnostic/staging tests for lung cancer

A

CXR
CT (staging)
PET scan

Tissue biopsy (endoscopy or video assisted thoracoscopic surgery)
Cytology (from aspirates, washings, pleural fluid)
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15
Q

Squamous cell carcinoma histological findings

A

Kertain
Intercellular bridging
Necrosis

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16
Q

Interstitial lung disease characteristics and investigations

A

Dry hacking cough
Dry crackles
Chronic hypoxaemia
Restrictive lung pattern

Lung function test: raised or normal FEV1/FVC
CXR: reticular and nodular
Biopsy (VATS)
High res CT: ground glass appearance

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17
Q

Interstitial lung disease treatment

A

Steroids

DMARDs, biologics

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18
Q

Sarcoidosis clinical features

A

Black females more at risk

Pulmonary: Bilateral hilar lymphadenopathy, fine insiratory crackles, breathlessness

Hypercalcaemia

Erythema nodosum (painful red nodules, shins)

Ocular: uveitis (iritis, intermediate, choroiditis), keratoconjunctivitis sicca (dry eyes), secondary glaucoma

Facial palsies
Carotid enlargement
Cardiac involvement

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19
Q

What blood tests are useful to do for someone with suspected sarcoidosis?

A 
FBC, U&Es, LFTs
Bone profile (hypercalcaemia may be seen)
Serum ACE (raised, levels show response to treatment)
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20
Q

Imaging findings for sarcoidosis

A

CXR: hilar lymphadenopathy, reticular opacities

High res CT: ground glass, diffuse nodularity, reticular changes

Fibrosis affecting upper lobes

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21
Q

What would you see on a bronchoalveolar lavage with biopsy for sarcoidosis?

A

Inversion of CD4/CD8 ratio
Raised lymphocytes
Non-caseating granulomas on biopsy

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22
Q

Staging system for sarcoidosis

A 
0: normal CXR
I: bilateral lymphadenopathy
II: lymphadenopathy with pulmonary infiltrates
III: infiltrates alone
IV: pulmonary fibrosis
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23
Q

Indications for sarcoidosis treatment with corticosteroids?

A

Asymptomatic/I-III: no treatment

Symptomatic/IV: prednisolone (+osteoporosis prophylaxis if long-term) - reassess after 4-6 weeks

IF HYPERCALCAEMIA, EYE, HEART or NEURO involvement

Surgery for end-stage disease

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24
Q

What might you see in cutaneous sarcoidosis?

A

Papules on head or neck

Erythema nodosum

Lupus pernio (rash over nose and cheeks)

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25
Q

Most common causes of death in patients with sarcoidosis?

A

Pulmonary fibrosis
Cor pulmonale
Pulmonary hypertension
Myocardial disease

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26
Q

Bird fancier’s disease characteristics

A

Antigen mediated

Symptoms present during contact (e.g. while at work) but go away during holidays

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27
Q

Asbestosis clinical features and treatment

A

> 30 years exposure shipyards and construction

Barbell bodies on biopsy
Pleural plaques
Mesothelioma

Tx: stop smoking (patients have high mortality rate)
Industrial compensation
Surgery or chemo

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28
Q

What is sillicosis associated with?

A

Rock quarry and sand blasting

TUBERCULOSIS

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29
Q

Causes of upper lobe fibrosis (CHARTS)

A 
Coal workers' pneumoconiosis 
Hypersensitivity pneumonitis 
Aspergillosis 
Radiation 
TB 
Sarcoidosis/sillicosis
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30
Q

Causes of lower lobe fibrosis (CRABS)

A 
C (idiopathic pulmonary fibrosis)
RA 
Asbestosis 
Bleomycin 
SLE
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31
Q

Indicators for non-invasive ventilation

A

COPD with respiratory acidosis

Type 2 resp failure secondary to chest wall deformity, neuromuscular disease, obstructive sleep apnoea

Cardiogenic pulmonary oedema unresponsive to CPAP

Weaning off tracheal intubation

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32
Q

What is a Ghon complex?

A

Ghon focus and hilar lymph nodes seen in primary TB infection

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33
Q

Bacteria most likely to cause aspiration pneumonia

A

Strep pneumonia
H. influenzae
Staph aureus
Pseud. aeruginosa

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34
Q

Initial COPD management

A

Stop smoking
one off pneumococcal vaccination
annual influenza vaccination
pulmonary rehab

SABA and SAMA

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35
Q

What are asthmatic features/features suggesting steroid responsiveness?

A

Raised eosinophil count
Variable FEV1
Diurnal PEF variation

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36
Q

What is the treatment of COPD after SABA/SAMA

A

Asthmatic features: ICS and LABA (+LAMA e.g. tiotropium if needed)

No asthmatic features: LABA and LAMA

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37
Q

What abx prophylaxis do you give COPD patients and what investigation do you need to carry out for side effect?

A

Oral azithromycin (IF NON-SMOKER)

ECG for prolonged QT

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38
Q

First line treatment in diagnosed asthma

A

ICS

SABA as required (unless on MART) - if using more than 3 times a week, consider next step

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39
Q

First line treatment for acute severe asthma

A

Nebulised salbutamol, nebulised ipratropium bromide, oral prednisolone

IV magnesium sulphate and aminophyline (if initial treatment ineffective)

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40
Q

How do you give oxygen to COPD patient with acute exacerbation?

A

Venturi 28%

15L non-rebreather high flow if critically hypoxic

41
Q

How do you assess severity of stable COPD?

A

FEV1 (%predicted)

42
Q

Causes of hemithorax white out

A

Trachea pulled towards whiteout: pneumonectomy, lung collapse, pulmonary hypoplasia

Trachea central: consolidation, mesothelioma, pulmonary oedema (usually bilateral)

Trachea pushed away from whiteout: pleural effusion, diaphragmatic hernia, large thoracic mass

43
Q

Causes of multiple ill-defined opaque foci on a CXR?

A 
RA
Lung metastases
Septic emboli
Granulomatosis with polyangiitis (Wegners) 
Pulmonary infarcts
44
Q

What treatment can be given to a patient with mesothelioma?

How is it usually diagnosed?

A

Injection of sclerosant substances to prevent reaccumulation of pleural effusion

Diagnosed with thoracoscopy with histology of pleura

45
Q

Causes of miliary shadowing on x-ray

A 
TB
Lung mets
Sarcoidosis 
Occupational lung disease 
Extrinsic allergic alveolitis
46
Q

What 5 ways can aspergillus affect the lung?

A

Type I hypersensitivity in asthma

Allergic bronchopulmonary aspergillosis - type I and III hypersensitivity with recurrent asthma and bronchiectasis

Mycetoma (aspergilloma) - fungus ball forming in pre-existing lung cavity

Invasive aspergillosis (in immunosuppressed) - high mortality

Extrinsic allergic alveolitis - dry cough, dyspnoea and fibrosis

47
Q

What are the characteristics of allergic bronchopulmonary aspergillosis

A

Eosinophilia
Serum precipitins
Raised IgE
Positive aspergillus skin test

48
Q

Management of primary pneumothorax

A

If <2cm rim of air and no SOB - discharge

ASPIRATE

if still >2cm or SOB then CHEST DRAIN

Avoid smoking

49
Q

Common causes of respiratory alkalosis (low CO2)

A 
Pregnancy 
PE 
Anxiety 
CNS disturbances (stroke, encephalitis) 
Salicylate poisoning 
Altitude
50
Q

Staging of COPD

A

FEV1 predicted

1: >80%
2: 50-79%
3: 30-49%
4: <30%

51
Q

Features of A1AT disease?

A

Emphysema of lower lobes (COPD picture with worsening SOB, chest pain, cough)

Liver cirrhosis or cholestasis in children

52
Q

Management of A1AT

A

No smoking
Bronchodilators and physio
IV alpha-1 antitrypsin protein
Lung volume reduction surgery/transplant

53
Q

A1AT disease inheritance pattern

A

Autosomal recessive/co-dominant

54
Q

Definition of ARDS

A

Bilateral pulmonary infiltrates, severe hypoxaemia

in absence of cardiogenic pulmonary oedema (normal pulmonary capillary wedge pressure)

CXR looks like pulmonary oedema

55
Q

Causes of ARDS

A 
Acute pancreatitis 
Sepsis 
Trauma 
Lung injury 
Long bone fracture 
Head injury
56
Q

Management of ARDS

A

Treat underlying cause
ABx if sepsis
Diuretics

SMALL, SHALLOW, FAST BREATHS (avoid CO2 accumulation)
Mechanical ventilation using low tide volumes
Positive end expiratory pressure or prone ventilation

57
Q

Features of ARDS

A

Acute dyspnoea and hypoxaemia (P/A <200) hours/days after event

Multi organ failure

Rising ventilatory pressures

58
Q

What is Lights criteria?

A

LDH fluid >2/3
LDHf/LDHs >0.6
TPf/TPs >0.5

Protein >30g/L

Any ONE positive = exudate
All negative = transudate

59
Q

Causes of transudate pleural effusion

A

CHF
Cirrhosis
Gastrosis
Nephrosis

60
Q

Causes of exudative pleural effusion

A

Malignancy
Pneumonia
TB
PE

61
Q

What would you see in a pleural effusion in TB

A

Lymphocytosis (also in cancer)

Ada

62
Q

When is thoracentesis contraindicated in pleural effusion?

A

Too small (<1cm)

Loculated (septations or lobes)

CHF (use diuretics instead if they have CHF)

63
Q

Management of loculated pleural effusion

A

Thoracostomy

Thoracotomy if that fails

64
Q

Pleural effusion imaging

A

PA CXR
Ultrasound: guides aspiration, can identify fluid septations
CT: underlying disease

65
Q

Organisms that most commonly cause infective exacerbations of COPD?

First-line treatment?

A
  1. H influenzae
    Strep pneumoniae

Tx: amox or co-amox
Clarithromycin or doxycycline if pen allergy

66
Q

Causes of widening mediastinum on CXR?

A 
Lymphoma
Retrosternal goitre
Teratoma 
Thoracic aortic aneurysm 
Tumour of the thymus
67
Q

Difference between severe and life-threatening asthma attack

A

Severe: >110 bpm, 33-50% PEF, can’t speak in full sentences, RR>25

Life-threatening: <33% PEF, silent chest, pO2<92%, cyanosis, bradycardia

68
Q

Wegener’s vs Churg-Strauss

A

Wegeners: renal failure, epistaxis, haemoptysis, cANCA

Churg-Strauss: asthma, eosinophilia, pANCA

Both: vasculitis, sinusitis, dyspnoea

69
Q

Management of asthma attack - guidelines for escalation

A
  1. Oxygen
  2. Salbutamol nebs
  3. Ipratropium nebs
  4. IV hydrocortisone or oral pred
  5. IV magnesium sulphate
  6. aminophyline or IV salbutamol
70
Q

1 pack year?

A

25 cigs per day for one year

71
Q

Parallel line shadows (tram lines) on x-ray

A

Bronchiectasis

72
Q

Long-term changes on FBC in COPD

A

Polycythaemia (raised haematocrit due to prolonged hypoxia and increased EPO production)

73
Q

Stepwise management of asthma

A
  1. SABA
  2. SABA and ICS
  3. SABA and ICS and LTRA
    • LABA
  5. switch ICS and LABA for MART
  6. medium dose ICS MART
  7. change MART to high dose ICS or add antimuscarinic/theophyline or refer to specialist
74
Q

Most common causes of bilateral hilar lymphadenopathy

A

Sarcoidosis and TB

Lymphoma
Pneumoconiosis
Fungi

75
Q

Features of Klebsiella pneumonia

A

Red-currant jelly sputum
Alcoholics and diabetics
Following aspiration
Affects upper lobes

76
Q

Management of low-severity CAP

A

Oral amox 5 days (macrolide if allergy)

77
Q

Management of mod and high-severity CAP

A

Amox and macrolide

Consider co-amox/ceftriaxone with macrolide and tazobactam

78
Q

Where do you treat a pneumonia patient with:
CURB 2 or more?
CURB 3 or more?

A

> 2: admit

>3: intensive care

79
Q

Diagnostic investigation for asbestosis?

A

Thoracoscopy and histology (usually following a CXR and pleural CT)

80
Q

What pH should an aspirate from an NG tube be before it is safe to use?

A

<5.5

81
Q

In which patients should you avoid clarithromycin in?

A

Long QT syndrome

82
Q

When would you give a COPD patient azithromycin prophylaxis?

A

DON’T SMOKE

Optimised vaccinations and referred for pulmonary rehab

Continue to have >4/year exacerbations with sputum, prolonged exacerbations or hospitalisation

83
Q

Emergency aspiration for pneumothorax - landmark?

A

Mid-clavicular, 2nd intercostal space

84
Q

Chest drain triangle of safety?

A

Base of axilla, lateral edge of pec, 5th intercostal space, anterior border of latissimus dorsi

85
Q

Indications for surgery in bronchiectasis?

A

Localised disease

Uncontrolled haemoptysis

86
Q

Which COPD patients should you assess for long-term oxygen therapy?

A 
Polycythaemia 
Severe airflow obstruction (PEF <30%)
Peripheral oedema 
Raised JVP
Sats <92% on room air 
Cyanosis
87
Q

What does LTOT assessment entail?

A

Two ABGs two weeks apart

pO2 <7.3kPa or pO2 7.3-8kPa with one of:
Secondary polycythaemia
Peripheral oedema
Pulmonary hypertension

88
Q

Contraindications to lung cancer surgery?

A 
SVC obstruction 
FEV <1.5
Vocal cord paralysis 
Malignant pleural effusion 
Tumour near hilum
89
Q

Criteria for asthma diagnosis?

A

Exhaled FeNO >40 parts per billion
Diurnal PEF variation of >20%
Post-bronchodilator FEV1 improvement of >12% or 200mL lung volume
FEV1/FVC <70%

90
Q

CXR findings in heart failure

A 
Alveolar oedema (bat wings)
B Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
Effusion (pleural)
91
Q

When to give patients with URTI abx?

A

Otorrhoea
Meet Centor criteria for tonsilitis
<2 years with bilateral acute otitis media

92
Q

Pneumothorax differential in smokers with COPD?

A

Emphysematous bullae

Appear lucent without a visible war and >1cm

93
Q

What is the main criteria for a COPD patient being offered LTOT?

A

Two ABG readings <7.3kPa oxygen

94
Q

Lung cavitation differentials

A 
Abscess (Klebsiella, Staph, pseudomonas)
Wegener's 
TB 
SCC
RA
PE
Aspergillosis
95
Q

Management of secondary pneumothorax (if underlying lung disease)

A

> 2cm CHEST DRAIN
1-2cm ASPIRATE
<1cm oxygen and admit for 24 hours

96
Q

Three stages of Churg-Strauss disease, and what antibody is associated?

A
  1. Allergy, rhinitis, asthma
  2. Eosinophilia
  3. Vasculitis, renal failure, petechial rash

pANCA

97
Q

What drugs can cause secondary pulmonary fibrosis?

A

Amiodarone
Nitrofurantoin
Methotrexate

98
Q

Investigation for obstructive sleep apnoea?

A

Polysomnography

Identifying anatomical basis: cinematic MRI and sleep endoscopy

99
Q

Most common pulmonary manifestation of SLE?

A

Pleuritis with exudative pleural effusion

Phase 3b (18 decks)

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