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RW FY1 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Stepwise long-term management of Asthma

A

(1) SABA
(2) SABA + ICS
(3) SABA + ICS + LTRA
(4) SABA + ICS + LABA

+/- Continue LTRA depending on their response to LTRA

(5) SABA + MART (w/ Low-dose ICS)
(6) SABA + MART (w/ Moderate-dose ICS)
(7) Specialist
- Muscarinic receptor antagonist
- Theophylline
- High dose ICS
- Oral prednisolone

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2
Q

Causes of upper lobe fibrosis

A

Tip: CHARTS

Coal workers pneumoconiosis

Hypersensitivity pneumonitis (= EAA)

Ank Spond + Aspergillosis (ABPA)

Radiation

TB

Sarcoidosis + Silicosis

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3
Q

Causes of lower lobe fibrosis

A
  • Asbestosis
  • Connective tissue disorders (except Ank Spond –> Aprical)
    • RA
    • SLE
    • Scleroderma
    • Sjogren’s
    • Polymyositis / Dermatomyositis
  • Idiopathic pulmonary fibrosis
  • Drug-induced pulmonary fibrosis (BS NAME)
    • Bleomycin, Busulfan
    • Amiodarone
    • Nitrofurantoin
    • Sulfasalazine
    • Methotrexate
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4
Q

Causes of drug related pulmonary fibrosis

A

Tip: BS NAME

  • Bleomycin, Busulfan
  • Amiodarone
  • Nitrofurantoin
  • Sulfasalazine
  • Methotrexate
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5
Q

Causes of bilateral hilar lymphadenopathy

A
  • TB
  • Sarcoidosis
  • Lymphoma
  • Pneumoconiosis
  • Fungi (Histoplasmosis, Coccidioidomycosis)
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6
Q

Classifying the different severities of Asthma

A
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7
Q

Define

  • Inspiratory capacity
  • Vital Capacity
  • Total Lung Capacity
  • Functional residual capacity
  • Residual Volume
  • Tidal Volume
  • Inspiratory Reserve Volume
  • Expiratory Reserve Volume
A
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8
Q

Borders of safe triangle

A
  • Base of the Axilla
  • Pectoralis major (lateral edge)
  • 5th ICS
  • Latissimus dorsi (anterior border)
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9
Q

Where to insert the chest drain

A

In safe triangle

ABOVE the rib

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10
Q

Obstructive pattern on spirometry is defined as

A

↓↓ FEV1 (<80% predicted)

↓ FVC (but decreases by a lesser extent)

FEV1:FVC < 70% (predicted) ==> Obstructive

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11
Q

Causes of obstructive lung disease

A

Asthma

COPD

Bronchiectasis

Bronchiolitis obliterans

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12
Q

Positive reversibility testing is defined as

A

↑ FEV1 which is > 200ml AND 12% of the pre-test value

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13
Q

Classification of severity of COPD

Name of classification?

Based on what factor?

A

GOLD Classification - based on FEV1

Mild COPD: FEV1 > 80% (predicted) - i.e. normalises after medication

Moderate COPD: FEV1 50-79% (predicted)

Severe COPD: FEV1 30-49% (predicted)

Very severe COPD: FEV1 < 30% (predicted)

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14
Q

Restrictive pattern on spirometry is defined as

A

↓ FEV1 (<80% predicted)

↓ FVC (<80% predicted)

FEV1:FVC ratio (>70%)

i.e. preserved ratio but absolute values for both FEV1 and FVC are both lower

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15
Q

Causes of restritive lung disease

A
  • Pulmonary fibrosis
  • Pneumoconiosis / Asbestosis
  • Extrinsic allergic alveolitis
  • Neuromuscular conditions
  • Sarcoidosis
  • Kyphoscoliosis / Ankylosing spondyltitis
  • Neuromuscular conditions (affecting diaphragm)
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16
Q

Next investigation if

FEV1 < 80% predicted

reduced FVC

FEV1:FVC ratio < 0.7

A

Bronchodilator reversibility testing

Reversible –> Asthma (increase FEV1 by 200ml and 12%)

Irreversible –> COPD

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17
Q

TLCO is defined as

A

Total factor of the Lung for Carbon Monoxide

= rate at which a gas will diffuse from the alveoli into the blood

Carbon monoxide is used to test the rate of diffusion

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18
Q

Causes of increased and decreased TLCO

A
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19
Q

Varenicline

Indication?

MOA?

C/I

A

Varenicline

Indication: Smoking cessation

MOA: ACh receptor agonist –> reduced cravings of nicotine

C/I in Pregnancy, Breastfeeding

Caution: increased suicidal thoughts

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20
Q

Bupropion

Indication

MOA

C/I

A

Bupropion

Indication: Smoking cessation

MOA: NA and Dopamine re-uptake inhibitor (atypical antidepressant)

C/I in Pregnancy and Breastfeeding

S/E: Seizures

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21
Q

Pulsus paradoxus

Definition

Causes

A

Pulsus paradoxus = difference between sBP on inspiration and expiration > 20mmHg

Causes

  • Severe asthma
  • Cardiac tamponade
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22
Q

PERF variability

cut off?

indicates?

A

PEFR variability = (highest PEFR - lowest PEFR) / (average PEFR)

Uncontrolled asthma have ↑ variability in PEFR (worse in morning)

Values > 20% variability suggests asthma

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23
Q

Ix for diagnosis of (stable) Asthma

if High probability

if Intermidiate probability

A

High probability –> Trial treatment + Spirometry (FEV1 or serial PEFR)

Intermediate probability –> Spirometry + Bronchodilator reversibility

Obstructive pattern on spirometry

  • ↓↓ FEV1 < 80% (predicted or best)
  • ↓ FVC
  • FEV1:FVC ratio < 70% (predicted or best)

+ve bronchodilator response

  • ↑ FEV1 which is > 200ml AND 12% of the pre-test value
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24
Q

Ix to exclude Asthma if -ve Spirometry and -ve PEFR variability

A

Bronchial challenge test (using Histamine)

Negative test excludes Asthma

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25
Q

Asthma attack given nebulised salbutamol

ECG changes show?

A

Salbutamol

S/E: Hypokalaemia

ECG changse: TWI + U waves + long QU interval

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26
Q

Severe Asthma given IV MgSO4

S/E?

A

IV MgSO4

Hypotension

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27
Q

Severe asthma started on IV aminophylline

S/E?

Monitoring?

A

IV Aminophylline

cardiac arrhythmias

Requires cardiac monitor

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28
Q

Examples of asthma therapy

SABAs

LABAs

ICS

LTRA

A

SABAs

  • Salbutamol
  • Terbutaline

LABAs

  • Salmeterol
  • Formeterol

ICS

  • Beclometasone dipropionate / Clenil
  • Budesonide

LTRA

  • Montelukast
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29
Q

Signs of well controlled asthma

A

Signs of well controlled asthma

  • No daytime symptoms or waking at night
  • No exacerbations
  • No need for reliver inhaler
    • Ideally, 1 SABA inhaler should last > 1 year
  • No limitations on activity (including exercise)
  • No asthma attacks
  • Normal lung function (PEFR > 80% of predicted or best)
  • Minimal S/E from medication
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30
Q

Kartagener’s syndrome triad

A

Kartagener’s syndrome

bronchiectasis

sinusitis

situs inversus

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31
Q

Causes of bronchiectasis

A
  • Post-infection (Haemophilus influenzae - most common)
  • Genetic
    • Cystic fibrosis
    • a1 antitrypsin
    • Kartagener syndrome (ciliary dyskinetic syndrome)
    • Yellow nail syndrome
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32
Q

CXR signs in bronchiectasis

A

CXR signs in bronchiectasis

  • Dilated bronchi / Tramtrack opacities
  • Caose, thickened bronchidal markings
  • Ring shadows (mainly in upper lobes)
  • Fibrosis
  • Atelelactasis
33
Q

Ix for bronchiectasis

A

HR-CT: [best diagnostic method for bronchiectasis]

  • Dilated airways
  • +/- thickened wall
  • Mucus plugs
  • Tram-track sign
  • Signet ring sign
34
Q

Management of bronchiectasis

A

Acute

  • Antibiotics
  • Bronchodilators
  • Hypertonic 3% saline nebs

Long term

  • Chest physiotherapy –> postural drainage
  • +/- Prophlactic ABx (Azithromycin)
  • +/- Surgical resection +/- Lung transplant
35
Q

a1 anti-trypsin deficiency

Mode of inheritence

Clinical features

A

a1 anti-trypsin deficiency

Autosomal recessive (PIZZ homozygous)

Presents with COPD in yougng people + Liver cirrhosis

36
Q

IECOPD - causes

A

IECOPD - causes

  • Viral URTI (30%)
    • Rhinovirus (most common viral cause)
  • Bacterial infection
    • Haemophilus influenzae (most common bacterial cause)
    • Streptococcus pneumoniae
    • Moraxella catarrhaslia
37
Q

Diagnosis of COPD

A

Spirometry

Post-bronchodilator FEV1/FVC ratio < 0.70 on spirometry is diagnostic for COPD

38
Q

Tx options which improve survival in COPD

A

ONLY smoking cessation + oxygen supplementation

have been shown to ↑ survival in COPD

39
Q

Stepwise management of COPD

A

Stepwise management of COPD

  1. SABA / SAMA

2A. If Asthmatic features or steroid responsiveness –> LABA + ICS

2B. If no asthmatic features or steroid responsiveness –> LABA + LAMA

  1. LABA + LAMA + ICS
40
Q

Cystic fibrosis

  • mode of inheritance
A

Cystic fibrosis

Autosomal recessive

Mutation in CFTR

ΔF508 is the most common mutation in the UK

41
Q

Most common organsisms in cystic fibrosis

A

cystic fibrosis

In Children –> S. aureus & H. influenzae

In Adults –> Pseudomonas aeruginosa (85%) + Burkholderia species

42
Q

Ix for Cystic fibrosis

A

Ix for Cystic fibrosis

  • Guthrie test: +ve = ↑ immunoreactive Trypsinogen (IRT) at birth
    • Part of UK newborn heel prick test performed @ 5-8 days olD
  • If +ve Guthrie test
    • Sweat test: Give Pilocarpine + measure [Cl-]
    • Genetic testing: confirm patient’s genotype +/- family testing
43
Q

Acute Tx for meconium ileus due to cystic fibrosis

A

(1) Gastrografin enemas + Lactulose
(2) Surgery +/- NG decompression

44
Q

Long term management of CF

A
  • Chest physiotherapy
  • +/- Salbutamol +/- ICS +/- Mucolytic +/- Prophylactic ABx
  • +/- CFTR modulator
    • Ivacaftor (not effective for F508del)
    • Orkambi (if F508del homozygous)
  • +/- Lung traplant
  • HIGH calorie + HIGH fat diet
  • Pancreatic enzymes
  • Fat-soluble Vitamin supplementation (ADEK)
45
Q

Cystic fibrosis - presentation

A

Cystic fibrosis

  • Newborns
    • Meconium ileus (distal small bowel obstruction)
    • Recurrent respiratory infections –> Bronchiectasis
    • Prolonged neonatal jaundice
    • Failure to thrive
    • Steatorrhoea
  • Young children
    • Rectal prolapse
    • Nasal polyps
  • Teenagers
    • Delayed puberty
    • Diabetes mellitus
    • Pancreatitis
    • Distal intestinal obstructural syndrome (DIOS)
    • Infertility
46
Q

Obstructural sleep apnoea

Ix?

Tx?

Cx?

A

Obstructural sleep apnoea

Ix: Polysomnography [diagnostic]

Epworth Sleep Scale

Tx: Weight loss +/- CPAP +/- Oral appliance therapy

Complications: Respiratory acidosis

47
Q

Ix for pulmonary fibrosis

A

High-resolution CT [diagnostic]

  • Reticular opacities
    • Worse at the bases + sub-pleural
  • (initially) Ground glass opacities
  • (later) Honeycombing
  • Traction bronchiectasis
48
Q

EAA - definition

CXR

Tx?

A

Extrinsic allergic alveolitis

= Hypersensitivity pneumonitis

= Interstitial inflammatory disease of the alveoli due to inhalation of organic dusts

  • Farmer’s lung = Mouldy hay
  • Pigeon fancier’s lung = Bird droppings
  • Mushroom worker’s lung = Compost (contains thermophilic actinomycetes)
  • Humidifier lung = Water-containing bacteria & amoeba
  • Maltworker’s lung
  • Barley or maltings (contains Aspergillus clavatus)

CXR: reticulonodular opacities with ground glass appearance

Tx: Avoid allergn +/- Prednisolone

49
Q

Tx and Cx of pulmonary fibrosis

A

Pulmonary fibrosis

Pulmonary rehabilitation

Anti-fibrotic therapy

  • Perfendione
    • ​C/I: eGFR < 30
  • Nintedanib

+/- Lung transplant

Complications: Pulmonary hypertension, Lung cancer

50
Q

CXR Pleural plaques

Management?

A

None required as do NOT undergo malignant change

Do NOT require follow up

51
Q

CXR shows egg shell calcification of hilar lymph nodes in upper lobes

Dx?

A

Silicosis

52
Q

Tx for mesothelioma

A

Tx for mesothelioma

(1) Surgery
(2) Chemotherapy

53
Q

Types of aspergillus lung disease

A

Aspergilloma

  • pre-existing lung cavity

Allergic broncho-pulmonary aspergillosis (ABPA)

  • Type I and III Hypersensitivity reaction to Aspergillus spores

Invasive aspergillosis

  • invades lung tissue –> fungal dissemination
54
Q

Definitive diagnosis of invasive aspergillosis

A

Galactomannan ELISA test

Definitive diagnosis of invasive aspergillosis

55
Q

Tx for aspergilloma

Tx for ABPA

Tx for invasive aspergillosis

A

Tx for aspergilloma

  • (1) Surgical resection
  • (2) Radiological embolisation

Tx for ABPA

  • Oral prednisolone

Tx for invasive aspergillosis

  • Voriconazole
  • Lipsomal Amphotericin B
56
Q

Common organisms causing pneumonia

A
57
Q

Productive, rusty coloured sputum

Cause

A

Streptococcus pneumoniae

58
Q

COPD + Pneumonia

Cause

A

Haemophilus influenza

59
Q
A
60
Q

Alcoholic + Pneumonia

A

Klebsiella pneumoniae

61
Q

Dry cough

Flu-like symptoms

Erythema multiforme

Young adult / Children

Ix? Dx?

A

Mycoplasma pneumoniae (atypical CAP)

Mycoplasma serology

62
Q

Stagnant water systems

Dry cough

Flu-like symptoms

Confusion

Hyponatraemia

Diagnosis? Ix?

A

Legionella pneumophila

Ix: Urinary Legionella antigen

63
Q

Dry cough

Flu like symptoms

Rose spots

Hepatosplenomegaly

Hepatitis

Dx? Risk factor?

A

Chlamydia psittaci

Birds

64
Q

ABx for atypical pneumonia

A

Usually –> (1) Macrolide

  • Azithromycin
  • Clarithromycin
  • Erythromycin

Chlamydia psittaci or Coxiella burnetii (Q fever) –> (1) Tetracycline (Doxycycline)

65
Q

Dx of TB

A

Sputum MC&S for TB –> Smear microscopy + staining for AFB

  • Ziehl-Neelson stain (operator dependent)
  • Auramine-Rhodamine stain (look for fluorescent AFBs, better sensitivity)

or

Bronchoscopy + Biopsy + Histology

  • Caseating granuloma (hallmark of TB)
66
Q

Paradoxical transient worsening of TB symptoms and lesions following anti-TB therapy

  • Fever
  • Worsening of CXR
  • Lymphadenopathy
  • Pleural effusions

Diagnosis?

A

Immune reconstitution inflammatory syndrome (IRIS)

Tx: Continue anti-TB therapy and anti-retrovirals, consider steroids

67
Q

S/E of TB medications

A
68
Q

Sputum culture grows Mycobacterium malmoense

Next Ix?

A

Repeat sputum culture

At least 2 samples if from a non-sterile source (as may be contamination)

69
Q

High Altitude > 2500 m

Headache

Nausea

Fatigue

Dx? Tx? Prevention?

A

Acute mountain sickness (AMS)

Tx: Descent

Prevention: Acetazolamide

70
Q

Altitude > 4000 m

Signs of pulmonary oedema

  • SOB
  • Productive cough
  • Pink, frothy sputum
  • Bibasal crackles

Dx? Tx?

A

High altitude pulmonary oedema

Descent +/- Oxygen

71
Q

Altitude > 4000 m

Headache

Ataxia

Papilloedema

Dx? Tx?

A

High altitude cerebral oedema (HACE)

Tx: Descent + Dexamethasone

72
Q

Progressive SOBOE

Fatigue

Loud P2

Dx?

Ix for screening? Ix for diagnosis? Ix for management?

A

Pulmonary hypertension

Screening Ix –> TTE

Diagnostic Ix –> R heart catherisation (pulmonary arterial pressure > 25mmHg)

Management Ix –> Vasodilator testing (Epoprostenol)

  • +ve response –> CCBs (Nifedipine)
  • -ve response
    • PDE-5 inhibitor (Sildenafil)
    • Endothelin receptor antagonist (Ambrisentan)
    • Prostacyclin analogue (Epoprostenol, Iloprost)
    • Guanylate cyclse stimulator (Riociguat)

Complications: VTE (Tx: + Warfarin), RVH, R heart failure

73
Q

Progressive SOBOE

Fatigue

Loud P2

Dx?

Ix for screening? Ix for diagnosis? Ix for management?

A

Pulmonary hypertension

Screening Ix –> TTE

Diagnostic Ix –> R heart catherisation (pulmonary arterial pressure > 25mmHg)

Management Ix –> Vasodilator testing (Epoprostenol)

  • +ve response –> CCBs (Nifedipine)
  • -ve response
    • PDE-5 inhibitor (Sildenafil)
    • Endothelin receptor antagonist (Ambrisentan)
    • Prostacyclin analogue (Epoprostenol, Iloprost)
    • Guanylate cyclse stimulator (Riociguat)

Complications: VTE (Tx: + Warfarin), RVH, R heart failure

74
Q

Classification of pleural effusion

A
75
Q

Causes of pleural effusion

A
76
Q

Diagnosis of pleural effusion

A

Pleural USS + Pleurocentesis

(diagnostic for pleural effusion)

77
Q

Tx of pleural effusion

A

Transudative

  • Furosemide
  • If symptomatic –> USS-guided Thoracentesis

Exudative

  • +/- Antibiotics
  • If symptomatic –> USS-guided Thoracentesis
  • If empyema –> Chest drain

If recurrent

  • Pleurodesis
  • Pleural catheter drainage
78
Q

Thoracentesis: Turbid effusion with pH < 7.2, ↓ glucose and ↑ LDH

Diagnosis?

Tx?

A

Empyema

Chest drain + IV Antibiotics

79
Q

Tx for stable pneumothorax

A

Primary pneumothorax in < 50 years old

  • < 2cm AND asymptomatic
    • (1) Observation +/- Oxygen + OP CXR
    • > 2cm or symptomatic
      • (1) Aspiration +/- repeat aspiration
      • (2) Chest drain

Secondary pneumothorax or > 50 years old

  • < 1cm AND asymptomatic
    • (1) Observation +/- Oxygen + OP CXR
    • 1-2cm AND asymptomatic
      • ​(1) Aspiration
      • (2) Chest drain
    • > 2cm or symptomatic
      • (1) Chest drain

RW FY1 (15 decks)

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