Respiratory Flashcards
1
Q
3 aspects if asthma
A
- Variable airflow obstruction
- Bronchial hyper-responsiveness
- Airway inflammation
2
Q
When is bronchial challenge testing done?
A
- For defence force
2. Atypical presentation
3
Q
How to assess degree of inflammation in asthma
A
- Eosinophil count
2. Exhaled Nitric oxide
4
Q
What is Samter’s triad
A
- Asthma
- Aspirin intolerance
- Nasal polyps
5
Q
Chronic asthma + Recurrent pulmonary infiltrates + Very high IgE = ?
A
Allergic broncho-pulmonary aspergillosis.
- Check for aspergillus sensitivity
6
Q
Symptoms of Eosinophilic Granulomatosis with polyangiitis
A
Common - asthma, nasal and sinus symptoms, and peripheral neuropathy.
Infrequent - cardiomyopathy, kidney disease, and gastrointestinal involvement
Can have haemoptysis if necrotizing.
7
Q
Add on therapies in Asthma
A
- Monteleukast - leukotrine receptor antaginist
- Macrolides - Azithromycin
- Tiotripium - LAMA
- MAB’s
8
Q
MAB in allergic asthma and efficacy
A
Omalizumab - targets IgE
reduce exacerbations by 50%
use only if IgE levels are high
9
Q
MAB in eosinophilic asthma and efficacy
A
Mepolizumab + Benralizumab - targets IL-5 receptor.
Use if eosinophilia only.
reduce exacerbations by 50%
10
Q
What is pulmonary rehab?
A
A 6-8 week program with education and exercise components.
11
Q
Difference in efficacy between dual COPD therapy (LAMA/LABA) and triple therapy (LAMA/LABA/ICS)
A
Reduced exacerbations in impact trial.
Increase risk of pulmonary infections.
12
Q
Causes of pleural effusions
A
CCF
Parapneumonic
Liver disease
Malignancy
13
Q
What does adenosine deaminase test for in pleural effusions?
A
High - TB/ infection
Very high - empyema/lymphoma.
14
Q
What is Lights criteria
A
- Fluid protein/Serium protein >0.5
- Fluid LDH/Serum LDH >0.6
- Fluid LDH > 2/3 ULN.
15
Q
pH for infective effusions
A
< 7.2
16
Q
Management of empyema/ infective effusions
A
- Abx
- Chest tube
- intrapleural tPA
- intrapleural DNAse
- VATs procedure
17
Q
Management of recurrent malignant effusions
A
- Indwelling pleural catheter (rocket drain) - use LENTS score.
- Talc pleurodesis.
18
Q
Zoonotic pneumonias
A
Tularemia - many animals Pasturella - Dogs and Cats Rhodococcus - horse, cow, pig Yersinia Pestis (Plague) - rodents/fleas Brucella - Slaughterhouses Coxiella Burnetti (Q fever) Psittacosis - birds Melioidosis - Northern Territory water
19
Q
CURB65 score
A
Confusion Urea RR BP Age >65
20
Q
Cause for increased risk of AMI post pneumonia
A
Cardiac microlesions.
21
Q
4 Types of respiratory failure
A
Type 1 - hypoxic
Type 2 - hypercapnic
Type 3 - Peri-operative
Type 4 - Shock related
22
Q
Benefit of prone position in ARDs
A
Increases alveolar utility
23
Q
Tidal volume and pressure in ARDs
A
Do not use high pressure or volumes.
Tidal volume <6ml/kg
Pressure <30cm
24
Q
Is there a survival benefit to long term O2?
A
Yes. If >15hrs/day.
No improvement in exacerbations of illness.
25
Effect of NIV in NMD
Improved morbidity AND mortality.
| Not effective to commence after bulbar dysfunction occurs.
26
Number of REM/Non-REM cycles in normal sleep
3-5 cycles
27
Sleep study types
Type 1 - 7 channels with clinician
Type 2 - 7 channels no clinician
Type 3/4 - <4 channels. For screening only
28
How to differential central vs obstructive apnoeas
If respiratory effort seen on polysomnogram
29
OSA diagnostic criteria
AHI > 5/hr + symptoms.
| AHI >15/hr +/- symptoms
30
Screening tests for OSA
Berlin test
OSA 50 test.
NOT Epworth scale - this is for sleepiness only.
31
Effect of CPAP on cardiovascular risk
CPAP DOES NOT affect cardiovascular risk.
32
Effects of CPAP
```
Increased cognitive function
Improved mood
Increased QOL
Improved BP control
Decreases MVA risk
```
33
Effect of Leptin in OHS
Leptin causes decreased appetite and increased ventilatory drive.
In obesity Leptin is low causing reduced ventilatory drive. Leads to chronic hypercapnoea.
34
Narcolepsy +/- Cataplexy diagnostic criteria
1. Daytime somnolence
2. Positive sleep latency test
3. 2x sleep onset REM periods (REM within 15mins sleep onset)
4. low CSF orexin/hypocretin (arousal hormones)
35
Management of Narcolepsy
Amphetamines
Modafenil
SSRI
36
Definition of bronchiectasis
Permanent dilation of bronchi and bronchioles due to destruction of airway muscles and elastic connective tissue.
37
Management of bronchiectasis
1. Chest physio
2. Inhaled hypertonic saline
3. Treat pseudomonas colonisation
4. SABA + LABA + LAMA + Steroids
38
Treatment of chronic inflammation in bronchiectasis
Macrolides - erythromycin
SE
- Resistance
- QT prolongation
- Mycobacterial infections.
39
Ix for Bronchiectasis
- Full blood count and major immunoglobulin classes G, A, M, E
- Sweat test in all children and selected adults - (see below)
- Culture airway secretions, including specialised cultures for mycobacteria, particularly nontuberculous mycobacteria (NTM) in sputum-producing patients
- Spirometry and lung volumes (when aged >6-years)
- Aspergillus serology.
40
Gene mutation in Cystic fibrosis
CFTR gene C7
| F508del
41
Management of cystic fibrosis
```
CFTR modulators
Inhaled DNAse
Macrolides
Hypertonic saline
Lung transplant.
```
42
CFTR modulators and MOA
Iva CaFToR - Potentiator - opens more Na/Cl channels in mutated CFTR. Used as monotherapy in gated mutations.
TezaCaFToR
Elexa CaFToR - Next generation - more effective
LumaCaFToR
MOA - Moves more mutated CFTR to cell surface, helps to correct the shape of the F508del mutation.
Used as combination therapy with Ivacaftor
Amplifiers - not yet available.
43
Inhaled Abx agents
Tobramycin
| Colistin
44
Non-respiratory CF complications
```
Pancreatic insufficiency
Meconium ileus
Distal intestinal obstruction (impaction in ileocecal junction)
GORD
rectal prolapse/ intersusseption
Bone disease
Absent vas deferens
```
45
Spirometry in obstructive lung disease
Low FEV1
| Low FEV1/FVC ratio
46
Spirometry in restrictive lung disease
Low FEV1
Lower FVC
High FEV1/FVC ratio
47
Large airway obstruction patterns
Fixed- flattened inspiration and expiration curves
- postintubation stenosis, goiter, endotracheal neoplasms, and bronchial stenosis.
Variable intrathoracic- flattened expiration curve (inspiration is pulled open by negative pressure)
- tracheomalacia, polychondritis, and tumors
Variable extrathoracic - flattened inspiration curve (expiration is pushed open by airflow) - vocal cord paralysis, vocal cord constriction
48
What are the signs/symptoms of dyskeratosis congenita?
Caused by shortened telomere length.
Signs/Symptoms - nail dystrophy, skin hyperpigmentation, leucoplakia, MDS, pulmonary fibrosis, deranged LFTs.
49
gene in ILD
MUC5b - affects mucocilliary clearance. Think lack of clearance = build up of muck.
UIP pattern on imaging.
Associated with Rheumatoid.
50
Management of scleroderma related ILD
Cyclosporin, Mycophenolate.
Autologous SCT
Nintedanib
51
skin changes + pneumomediastinum
| What is the disease and associated antibody?
amyopathic dermatomyositis.
| Check for anti-MDA5 antibody
52
Lytic bone lesions + purple papular rash + lymphadeopathy + cysts and nodules on CT with upper zone predominance.
Langerhans cell histiocytosis.
53
What is Lymphagioleiomyomatosis
Occurs in women of child-bearing age.
Can be associated with tuberous sclerosis
Progressive dyspnoea with costophrenic angle predominance.
54
Condition with GM-CSF antibodies
Pulmonary alveolar proteinosis
GM-CSF allows clearance of surfactant by macrophages.
55
Features of UIP on imaging
- Subpleural reticulation
- Worse at bases
- traction bronchiectasis
- Honeycombing
56
Differences between UIP and NSIP
UIP = honeycombing, NSIP = ground glass changes.
| NSIP has subpleural sparing
57
Treatment of idiopathic pulmonary fibrosis
Anti-fibrotic therapy
1. Pirfenidone - acts on TGF-beta
2. Nintedanib - inhibits tyrosine kinases PDGF, VEGF, FGF.
58
Features of UIP on histology
fibrotic lesions at different stages
| honeycombing
59
What are the Fleishner guidelines for solid lesions
<6mm - no follow up
6-8mm - 6month follow up CT
>8mm - single lesion - PET or biopsy.
Multiple lesions - 6 month follow up CT.
60
What are the Fleishner guidelines for subsolid lesions
<6mm - no follow up unless multiple lesions
| >6mm - CT at 6months then annually for 5years (years 3 and 5 only if ground glass)
61
Cause of tree-in-bud appearance
impaction of mucous, pus or blood
62
Causes for crazy paving appearance
pulmonary haemorrhage
Pulmonary alveolar proteinosis
ARDs
63
CT sign for bronchectasis
Signet ring sign
64
What are the 2 types of EBUS
Linear EBUS
| Radial EBUS - has 360 degree view - used for peripheral lesions.
65
Density of lung cancers
>20 Hounsfield units
66
Where are the chemoreceptors for the respiratory centre?
Carotid bodies
67
Normal A-a gradient for age estimate
(Age/4) +4
68
A-a gradient equation
PAO2 - PaO2
= (150 - 5/4x PaCO2) - PaO2
69
Causes of right shift of oxygen dissociation curve
low pH
high CO2
high temp
high 23BPG (binds DEoxygenated Hb)
70
MOA of mannitol in CF
Osmotic effect to thin secretions
71
Condition associated with upper lobe pulmonary fibrosis
Ankylosing spondylitis
72
What cell on BAL predicts steroid responsiveness in ILD?
Lymphocytes
73
Management of CAP complicated by large parapneumonic effusion.
Diagnostic thoracentesis and culture.
74
Causes of inaccurate Sats probe readings
```
Hb <50
Methaemoglobin
Carbon monoxide
Hypoperfusion
Hypothermia
```
75
What is methaemoglobin
Where the iron in haemaglobin is in the Fe3+ form instead of the Fe2+ form - does not allow O2 to bind.
76
Wells criteria
```
PE/DVT is #1 diagnosis
Clinical symptoms DVT
PMHx DVT or PE
Tachycardia
Immobilisation
Haemoptysis
Cancer
```
77
At what lung volume is pulmonary vascular resistance the lowest
Functional residual capacity
78
Criteria for secondary pneumothorax
Age >50 AND smoking Hx
OR
Evidence of underlying lung disease
All secondary pneumothoraxes must be admitted
79
Criteria for chest drain in pneumothorax
1. Primary pneumothorax >2cm or breathless and not relived by aspiration.
2. Secondary pneumothorax >2cm or failed aspiration in size 1-2cm
80
Which hormone stimulates respiratory drive
Progesterone
81
Afferent nerve in cough reflex
Vagus nerve
82
Pleural effusion with normal pH and low glucose
TB
| Malignancy
83
Parameter monitored in GBS respiratory crisis
FVC
84
dyspnoea a few days following Gemcitabine
Capillary leak syndrome (APO)
85
FBE finding in chylothorax
leukopenia
86
What is Platypnea-orthodeoxia
Dyspnoea and deoxygenation when changing from a recumbent to an upright position.
It is usually caused by increased right -to - left shunting of blood on assuming an upright
position, with normal pressure in the right atrium
87
Best investigation for Chronic thromboembolic pulmonary hypertension
VQ scan
88
Best test for cardiac cause of pulmonary oedema
Pulmonary capillary wedge pressure
89
Asthmatic with pneumonia + bilateral infiltrates that improves rapidly with steroids
Eosinophilic pneumonia.
Eosinophils drop quickly with steroids.
May be associated with Churg-Strauss.
90
Pulmonary function test that has the greatest variability
FVC
91
Pulmonary function tests post lobectomy
low DLCO and high DLCO/VA
92
In what form is majority of CO2 carried in the blood
bicarbonate ions
93
Which nerve supplies the diaphragm
Phrenic nerve
94
Physiological effects of OSA on the cardiovascular system
1. Increased sympathetic stimulation
2. Decreased L ventricular preload
3. Increased L ventricular afterload
4. Decreased stroke volume and BPduring apnoea and increased stroke volume after apnoea.
5. Hypoxia
95
REM sleep behaviour disorder increases risk of which disease
Parkinsons/ Multi-systems atrophy, Lewy body dementia
96
Changes to sleep in the elderly
Increased night time arousals, longer sleep latency, shorter sleep duration and increased daytime somnolence and napping. Reduced deep non-REM sleep.
97
What is slow wave sleep
Stage 3 and 4 of non-REM sleep. Non dreaming. Information storing.
98
Mutation in inherited pulmonary hypertension
Transforming growth receptors
- Bone morphogenic protein receptor type 2 (BMPR2)
- ALK1
99
MOA of Omalizumab
Binds directly to IgE and decreases IgE binding to receptors (on mast cells and basophils)
100
5 categories of pulmonary hypertension
1. Idiopathic/Inherited/ Drug induced/ Systemic disorder
2. Due to L heart disease
3. Due to chronic lung disease - ILD, COPD, OSA
4. Chronic arterial obstruction - CTEPH
5. Other/Unknown/Multifactorial
101
Treatment of pulmonary hypertension.
1. Check responsiveness to CCB in type 1
2. Ambrisentan/Bosentan
3. Sildenafil/ Tadalfil
4. Epoprostenol for Type 4.
102
DLCO in asthma
elevated
103
What part of the airways has the highest resistance?
Intermediate bronchi
104
MOA of Bosentan/Ambrisentan in Pulmonary HTN
Endothelin receptor blocker - causes vasodilation.
105
MOA of Sildenafil in Pulmonary HTN
Inhibits phosphodiesterase T5 (PDE5) in smooth muscle - causes vasodilation.
106
MOA of Riociguat in Pulmonary HTN
- Sensitises Guanylate cyclase to NO
| - Directly stimulates Guanylate cyclase
107
MOA of Iloprost in Pulmonary HTN
Prostacyclin receptor AGONIST
108
Most common pathogen that Cystic fibrosis patients are colonised with
Pseudomonas
109
Management of cystic fibrosis exacerbation with Pseudomonas colonisation
14 days ciprofloxacin + nebulised tobramycin or colistin
110
Management of cystic fibrosis exacerbation WITHOUT Pseudomonas colonisation
Augmentin 14 days or Bactrim + amoxycillin
| IV Beta-lactam + Aminoglycoside if severe
111
Type of asbestos which is oncogenic
blue fibres - amphiboles.
112
dyspnoea + chest wall pain
malignant mesothelioma.
Manage with radiotherapy - no benefit with chemo.
Avoid biopsy - high risk of seeding.
prognosis is 12months.
113
occupational exposure which increases the risk of TB infection
Silica
114
Role of Azithromycin in bronchiectasis
reduces exacerbations and sputum volume. prevents biofilm formation and inflammatory response to pseudomonas.
Patients require screening for Non-tuberculous mycobacteria are regular azithromycin will create resistance.
115
Highest risk conditions for pneumothroax
COPD
| PJP
116
Effect of carbon monoxide on O2 dissociation curve
Left shift - Hb tries to hang on to O2 as much as possible.
117
Nitrous oxide is elevated in which conditions
Asthma
Allergic rhinitis
NOT elevated in smoking
118
What percentage of adult onset asthma is due to occupational exposure?
5-20%
119
Most COMMON signs of PE (top 3 in order)
1. Dyspnoea
2. Tachypnoea
3. Pleuritic chest pain
120
Highest cause of mortality in lung transplant
Lung - Causes of death — Primary graft dysfunction (PGD), a form of ARDS/diffuse alveolar damage (DAD), which occurs in the early hours to days after transplant, is the leading cause of death in the first 30 days after transplantation, accounting for more than 25 percent of deaths
121
Subtypes of A1AT and disease caused
PIMM = normal
PIZZ = mutated = abnormal protein build-up = liver and lung disease
PI Null Null/ PIQQ = no protein = severe lung disease
122
Causes of a cavitating lung lesion
Infectious:
- Anaerobes
- Mycobacteria/ TB
- Nocardia
- Aspergillus
- Staph aureus/ Klebsiella
- Parasites - Entamoeba histolytica
Non- infectious
- PE with infarct
- GPA vasculitis
- Neoplasm
- Cysts
- Sarcoid
- Histiocytosis
123
Management of CTEPH
Pulmonary artery endarterectomy.
| if clear persistant segmental areas are present
124
Types of bronchial provocation testing
Mannitol - needs 15% change
Methacholine - needs 20% change
Mannitol is more specific.
125
What type of hypersensitivity is allergic extrinsic alveolitis (AKA hypersensitivity pneumonitis)
Type 3 (+ minimal type 4) - (despite the name)
126
Management of IECOPD
1. Inhalers
2. Steroids
3. Abx - NOTE, ABx is NOT necessarily needed for IECOPD, only if high volumes of purulent sputum is present with fever. If this is the case, can give Oral amoxycillin OR doxycycline. IV ABx is NOT required.
127
Mechanism for fall in pulmonary vascular resistance during exercise
dilation of pulmonary capillaries
128
Factors affecting pulmonary pressure
1. cardiac output
2. LA pressure
3. Pulmonary artery resistance
129
Physiological difference between men and women in lung function.
Men have a greater vital capacity (but not FEV1)
130
Disease caused by e-cigarettes
Eosinophilic pneumonia
Organising pneumonia
Lipoid pneumonia
131
Benefit of neuromuscular blockade in ARDs
No benefit. Outcomes for heavily sedated group with neuromuscular blockade and minimally sedated group were the same.
