Respiratory Flashcards
1
Q
Give some differentials for breathlessness of varying onset?
A
Few mins - PE, asthma exacerbation, pneumothorax, acute HF, inhaled FB
Mins to Hours - Pneumonia, COPD exacerbation
Hours to days - anaemia, pleural effusion, neuromuscular disorders
Chronic - Cancer, pulmonary fibrosis, COPD, Tuberculosis
2
Q
What other symptoms could indicate respiratory pathology?
A
Pleuritic chest pain Cough - productive/dry/haemoptysis Hyperventilation Fever/unwell Wheeze/stridor Use of accessory muscles
3
Q
What are some differentials for a cough?
A
GORD Pneumonia/TB COPD/Asthma HF Pulmonary fibrosis Drug induced Lung Cancer Psychogenic FB Cystic fibrosis Thyroid enlargement
4
Q
What are some differentials for a wheeze?
A
Sudden onset - FB and anaphylaxis
Fever - bronchitis/pneumonia/RTI
Previous atopy - Asthma
Adult - COPD/bronchiectasis/GORD
5
Q
What is the difference in differentials for a monophonic/polyphonic wheeze?
A
Mono - Large airways
Poly - Multiple small airways
6
Q
What are some causes for haemoptysis?
A
PE Vasculitis Bronchiectasis TB Pneumonia Trauma Post intubation CF Cancers
7
Q
What is blood streaked sputum indicative of?
A
Inflammation of the larynx/bronchi
Lung cancer
Ulcer
8
Q
What is pink sputum indicative of ?
A
Blood from alveoli
9
Q
What is green sputum indicative of?
A
Longstanding infection?
10
Q
What other sputum changes may be seen and what may they indicate?
A
Yellow/purulent - contain pus
White/grey - dehydrated
White, milky, opaque - viral
Frothy pink - pulmonary oedema
Rust - pneumonia, PE, TB
11
Q
What are the characteristics of asthma?
A
Reversible airflow limitation
Hyper responsive to range of stimuli
Bronchial inflammation
12
Q
How is asthma investigated? What are the results of these investigations?
A
Peak flow - morning and night
Spirometry - obstructive pattern
- 12% improvement with bronchodilator (and 200ml increase in volume in adults)
Nitrous oxide - raised levels
Corticosteroid trial - 2 weeks should induce 15% improvement
Skin prick
Provacation test - inhale histamines and 20% will have transient airflow limitation
13
Q
How is asthma diagnosed in children and adults?
A
Rare to diagnose <5 - clinical
5-16 - Bronchodilator reversibility. If negative or normal spirometry –> NO test
17y+:
- ask if symptoms impacted by work days - occupational?
- Spirometry with bronchodilator reversibility
- NO test
14
Q
What would constitute a positive nitric oxide test for asthma? Why does this occur?
A
> 40ppb in adults
35ppb in children
Inflammatory cells and in particular eosinophils have higher levels of NO synthases in them so NO is higher
15
Q
How is asthma managed?
A
1 - SABA PRN
2 - SABA + low dose ICS
3 - SABA + ICS + LRTA
4 - SABA + ICS + LABA (+LRTA if effective)
5 - SABA + MART (fast acting LABA + low dose ICS) (+LRTA)
6 - increase MART dose to medium
7 - increase dose again, specialist advise or additional drug such as theophylline
Step up if symptoms 3+ times/week or night time waking
16
Q
When is asthma treatment stepped down?
A
Consider every 3 months or so
Reduce steroid dose by 25-50%
17
Q
What are the stages of an acute asthma attack?
A
Mild Moderate Severe Life-threatening Near fatal
18
Q
How is asthma ranked into stages?
A
Based on O2 Sats, RR, HR, Speech, Wheeze, PEFR
Mod - sats >92%, RR<25, HR<110, wheeze, PEFR 50-75%
Severe - sats <92%, RR and HR increase, not speaking in sentences, may not have wheeze, PEFR 33-50%
Life threatening - NORMAL pCO2!!. sats<92%/cyanosed, bradycardic, no resp effort, silent chest, PEFR <33%, hypotensive.
Near fatal - HIGH pCO2, req. mechanical ventilation with increased inflation pressures
19
Q
How is acute asthma managed?
A
1 High flow O2 and Nebulised salbutamol 5mg back to back
2 Nebulised ipratropium bromide 500mcg
3 Oral pred 40mg or IV hydrocortisone 100mg
4 IV Magnesium sulphate 2g
5 Senior support - can use IV salbutamol or aminophylline
20
Q
What is the discharge criteria for asthma?
A
Stable on discharge meds for 12-24hr
Inhaler technique checked
PEFR >75%
21
Q
What are the two main causes of COPD?
A
Alpha 1 antitrypsin deficiency
Smoking
22
Q
How does COPD present? (Signs, symptoms, investigation findings)
A
Symptoms:
- Cough
- SOB
Signs:
- Pursed lip breathing
- Hyper-resonant
- Reduced breath sounds and wheeze
- Barrel chest
Spirometry:
Obstructive pattern with no reversibility
CXR:
- Flat diaphragm
- Hyperlucent lungs
- Wheeze
Pulmonary HTN –> cor pulmonale –> large p waves on ECH
23
Q
How is COPD categorised?
A
Using PEFR
Mild >80
Mod 50-79
Severe 30-49
V Severe <30
24
Q
How is COPD investigated? What are the results of these investigations?
A
Post bronchodilator spirometry - FEV1/FVC remain <70
CXR - bullae can look like pneumothorax, flat diaphragm
FBC - rule out secondary polycythaemia
BMI
25
How is COPD managed?
Lifestyle:
- Stop smoking
- Pulmonary rehab
- Annual influenza vaccine
- One off pneumococcal vaccine
```
Drugs:
- SABA or SAMA
If previous atopy, eosinophilia or diurnal variation:
- LABA + ICS
- LABA + LAMA + ICS
If no asthmatic features:
- LABA + LAMA
```
Can consider lung reduction surgery
26
When is theophylline used in COPD?
After trials of LABA and LAMA
27
When is Abx prophylaxis offered in COPD? What antibiotic is given and what monitoring is required?
If >3 steroid requiring or 1 hospital requiring exacerbation
Azithromycin
- LFT and ECG must be done (long QT)
- CT thorax to exclude bronchiectasis
- Sputum culture to exclude atypical/TB
28
Which organisms are typically responsible for infective exacerbations of COPD?
H Influenza - most common
| Strep pneumoniae
29
When are mucolytics considered in COPD management?
Chronic productive cough
30
What are the features of cor pulmonale and how is it managed in COPD patients?
Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud p2
Use loop diuretic and consider long term O2 therapy
ACEi, Ca blockers and alpha blockers not recommended
31
When is long term oxygen therapy considered in COPD? What happens in it?
```
pO2 <7.3 OR
pO2 7.3-8 AND one of
- secondary polycythaemia
- pulmonary hypertension
- peripheral oedema
```
Not offered if pt. continue to smoke
Must do risk assessment - risk of fire/falling over equipment
Patients do at least 15 hours per day
32
Which patients would you assess for long term O2 therapy in COPD?
```
Severe airflow obstruction
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
O2 sats 92 or less
```
33
How is an acute exacerbation of COPD managed?
SABA + 5 days prednisolone + amoxicillin (IF prurulent sputum/ pneumonia signs)
or clarithromycin or doxycycline if penicillin allergy
34
What commonly causes pneumonia?
Community acquired - S pneumoniae, H Influenza
Hospital acquired - S Aureus (and IVDU), pseudomonas
35
Which individuals is klebsiella pneumonia common in? What are some classical features?
Alcoholics and diabetics
- Red current jelly sputum
- Cavitating upper lobe lesion
36
Which individuals commonly get legionella pneumonia? What are some classical blood findings?
Those near air conditioning units
Hyponatraemia and lymphopenia
37
What type of pneumonia is common in individuals with HIV? What are some characteristic features of this pneumonia?
Pneumocystis jiroveci
Dry cough
Exercise induced desaturations
Absence of chest signs
38
How does mycoplasma pneumonia present? What is seen in CXR? How is it diagnosed? What are some complications?
Flu like progressing to dry cough
CXR: Often bilateral consolidation
Diagnosis: +ve cold agglutination test
Complications: haemolytic anaemia, erythema mutliforme, any 'itis' eg nephritis, meningitis
39
How is pneumonia managed?
a) CAP
b) HAP
c) Mycoplasma
d) Pneumocystis
CAP - 5 days amoxicillin (mild). May need 10 days co-amoxiclav or Tazocin if severe
Hospital - IV co-amox
Mycoplasma - Erythromycin
Pneumocystis - co-trimoxazole
40
What investigations are recommended for pneumonia?
```
Sputum MC&S
Blood culture
FBC - raised WCC, ESR and CRP
CXR
ABG
```
41
How is pneumonia scored and what is the recommendation?
CURB65:
- Confusion
- Urea >7
- RR >30
- BP <90/60
- >65yo
If score 2+ --> hospital
42
What is the discharge criteria for pneumonia?
Don't discharge if they have had 2+ of following in last 24 hr:
- Temp >37.5
- RR >24
- HR >100
- BP <90
- Sats <90
- Inability to eat unassisted
- Abnormal mental status
43
What is the post discharge information given for pneumonia (in terms of how it will develop)?
1 wk - fever resolve
4 wk - chest pain and sputum should be v reduced
6 wk - cough and breathlessness should be v reduced
3 months - most symptoms resolved but mild fatigue
6 months - most people back to normal
44
What are some complications associated with pneumonia?
```
Resp failure
Pneumothorax
Abscess
AF
Stroke
Pleural effusion
Sepsis
```
45
What is pulmonary fibrosis characterised by?
Scar tissue
Decreased compliance --> restrictive pattern
Honeycomb lung
46
What are the features of interstitial lung disease?
Dry cough
Dyspnoea
Digital clubbing
Diffuse inspiratory crackles
47
What are the risk factors for interstitial lung disease?
```
Idiopathic - male and 50-70yo
Coal workers - asbestos exposure
Bird keepers - pigeon fanciers
Drugs - amiodarone, bleomycin, nitrofurantoin, methotrexate
Rheumatoid arthritis
Sarcoidosis
Goodpastures
```
48
How would you investigate lung fibrosis?
Spirometry - restrictive picture
Impaired transfer factor - TLCO
Imaging - CXR and CT
49
How is lung fibrosis managed?
Pulmonary rehab
Steroids
Pirfenidone may be useful - antifibrotic
50
What changes are seen on imaging in lung fibrosis?
Bilateral insterstitial shadowing
Ground glass appearance which progresses to honeycombing
CT gold standard and req. for diagnosis
51
Which causes of lung fibrosis predominantly affect the upper lobes?
```
Hypersensitivity
Coal workers
Sarcoidosis
Ank spond
TB
```
52
Which causes of lung fibrosis typically affect the lower lobes?
Idiopathic pulmonary fibrosis
Drugs
Asbestosis
Lupus
53
How can asbestos affect the lungs?
Pleural plaques
Pleural thickening
Asbestosis - related to length of exposure, lower lobe fibrosis
Mesothelioma - Malignant disease of pleura
Lung cancer
54
What are the most common causes of bilateral hilar lymphadenopathy?
Sarcoidosis
TB
Others: lymphoma, pneumoconiosis, fungi
55
What is a mesothelioma?
Cancer of the mesothelial layer of the pleura
Highly associated with asbestos
Metastasise to contralateral lung and peritoneum
Right lung more often affected than left
56
How do mesothelioma's present?
```
Dyspnoea
Weight loss
Chest pain
Clubbing
30% - painless clubbing
Hx of asbestos exposure
```
57
How is mesothelioma investigated
CXR
CT
If pleural effusion - MC&S, biochem and cytology
Thoracoscopy for cytology negative exudates
Biopsy if pleural nodularity on CT
58
How are mesothelioma's managed?
Symptomatic
Industrial compression
Surgery/chemo
Poor prognosis - median 1 yr survival
59
What are some risk factors for a pulmonary embolus?
```
Age
Varicose veins
Recent foreign travel
Immobility
Recent surgery
Cancer
Oestrogen/COCP
Factor V leiden,
Infection
```
60
How does a pulmonary embolus present?
```
Breathlessness
Acute pleuritic chest pain - worse on inspiration
Haemoptysis
Tachycardia
Palpitations
Dizziness/syncope
```
61
What is in the well's score?
```
3 - Clinical signs of DVT
3 - Other diagnosis unlikely
1.5 - Recent immobility >3 days -
1.5 - Previous hx of DVT/PE
1.5 - Tachycardia
1 - Malignancy
1 - Haemoptysis
```
Score >4 - likely PE - do CTPA/VQ scan and start treating
Score <4 - PE unlikely, do D Dimer - if + CTPA
62
How is a pulmonary embolus managed?
Start treatment dose rivaroxaban while waiting for scan results if wells >4
Manage with DOAC's in normal and cancer
If severe renal impairment - LMWH then warfarin
Haemodynamically unstable - thrombolyse
63
How long are patients with a pulmonary embolus anti coagulated for?
Provoked - 3 months
Active cancer - 3-6 months
Unprovoked - 6 months
Weight up with HASBLED score
64
What can be used in individuals who have recurrent pulmonary embolisms?
IVC filter however weak evidence
65
Which pulmonary embolism patients can be managed as outpatients?
Those who are classified as low risk.
BTS recommend use of PESI score for risk stratification
66
What ECG changes are seen in pulmonary embolism?
Typically sinus tachycardia
Can see S1Q3T3 - deep S wave, path Q wave, t wave invert
RBBB and Right axis deviation
67
What would a CXR show in a pulmonary embolism?
Typically normal - done to exclude other pathology
May find wedge shaped opacification
68
What can cause a VQ mismatch on a scan?
PE
AV malformation
Vasculitis
Previous radio
69
Where may a CTPA fail to pick up a pulmonary embolus?
Emboli in the sub segmental arteries
70
What happens in tuberculosis?
When a non immune individual is exposed to M. Tuberculosis, a primary infection leading to a Ghon focus develops.
In immunocompetent people, this heals by fibrosis and remain dormant but in immunocompromised, it may lead to disseminated infection
If a patient later becomes immunocompromised, the dormant TB can reactivate in secondary TB.
This can spead locally or to distant sites.
71
What forms a Ghon complex?
Tubercle-laden macrophages - Ghon focus
| Hilar lymph nodes
72
Where can secondary tuberculosis spread?
```
CNS - tuberculous meningitis
Vertebral body - Pott's disease
Cervical lymph nodes - scrofuloderma
Renal
GI tract
```
73
What screening tools are used for TB?
Mantoux test - tuberculin skin test
Interferon gamma
74
What does the tuberculin skin test tell you?
If positive - whether a patient has had exposure to TB (active or latent)
Negatives can be false negatives - military TB, sarcoid, HIV, lymphoma, v young age
75
What is the advantage to interferon gamma over the tuberculin skin test?
Increased ability to detect latent TB in BCG vaccinated individuals
Neither good at determining between active and latent
76
How is tuberculosis investigated?
CXR - upper lobe cavitation and bilateral hilar lymphadenopathy
Sputum culture - gold standard
Sputum smear - 3 samples - Ziehl Neilson
NAAT - rapid diagnosis
FBC and LFT's
77
How does tuberculosis present?
```
Fever
Cough
Night sweats
Weight loss
Haemoptysis
Malaise
Pleural effusion
```
78
How is active tuberculosis managed?
RIPE
6 months of Rifampicin and Isoniazid (with pyridoxine)
2 months of Pyrazinamide and Ethambutol
79
How is latent tuberculosis managed?
3 months Isoniazid (with pyridoxine) and rifampicin
OR
6 months Isoniazid (with pyridoxine)
80
Who may directly observed therapy be used in for tuberculosis?
Homeless people with active TB
People with poor compliance
All prisoners
81
What are the adverse effects associated with tuberculosis management?
Immune reconstitution disease - enlarged lymph nodes 3-6wks post treatment
Rifampicin - orange secretions, hepatotoxicity, CYP inhibitor
Isoniazid - peripheral neuropathy, hepatitis, CYP inducer
Pyrazinamide - Arthralgia, gout, hepatitis
Ethambutol - optic neuritis
82
What is bronchiectasis?
Chronic inflammation of the bronchi and bronchioles leading to permanent dilation and thinning
83
What causes bronchiectasis?
- Post infective - TB, Measles, pertussis, pneumonia
- Cystic fibrosis
- Bronchial obstruction - FB or tumour
- Immune deficiency - selective IgA, hypogammaglobulinaemia
- Allergic bronchopulmonary aspergillosis
- Kartageners/youngs syndrome
- Yellow nail syndrome
84
What happens in bronchiectasis?
Poor mucus clearance so predisposed to infection by:
- H Influenzae
- S Pneumoniae
- Klebsiella
- Pseudomonas
85
How does bronchiectasis present?
Persistent cough
Copious sputum
Intermittent haemoptysis
Clubbing
Coarse inspiratory creps
Wheeze
86
How is bronchiectasis diagnosed?
High resolution CT - cystic shadows and thickened bronchial walls
87
How is bronchiectasis managed?
Airway clearance techniques
Mucolytics
Postural drainage
Abx - rotate! if pseudomonas - ciprofloxacin
Supportive measures - flu vaccines and bronchodilators
Surgery can be considered
88
What is cystic fibrosis?
Autosomal recessive mutation of the CFTR gene leading to defective chloride secretion and increased sodium absorption
89
What are the features of cystic fibrosis?
```
Recurrent infections
Chronic sinusitis
Nasal polyps
Infertility in males
Malabsorption - failure to thrive, Steatorrhoea
Abnormal sweat
Liver disease - portal hypertension, gallstones
Osteoporosis
Arthropathy
Distal intestinal obstruction syndrome
Diabetes mellitus
```
90
Which bacteria commonly colonise in cystic fibrosis patients?
Staph aureus
Pseudomonas
Aspergillus
Burkholderia
91
How is cystic fibrosis diagnosed?
Usually picked up on skin prick testing at birth
Can do sweat testing
Diagnosis:
- Positive hx in sibling or newborn screening result AND
one of
- >60mmol/L chloride conc on sweat test
- 2 CF mutations
- abnormal nasal epithelium ion transport
92
How does cystic fibrosis present in the neonatal period?
Meconium ileus
| Prolonged jaundice
93
What is are the common causes for a negative sweat test?
Main - Skin Oedema - pancreatic exocrine insufficiency
Others - malnutrition, glycogen storage disease, adrenal insufficiency, nephrogenic diabetes insipidus, G6PD, hypothyroid/parathyroid, ectodermal dysplasia
94
How does meconium ileus present?
Bilious vomit
Abdo distension
Delay in meconium passage
95
How is cystic fibrosis managed?
```
Chest physio and postural drainage
Abx prophylaxis
Mucolytics
Creon - Vit ADEK
High fat high calorie diet
Regular diabetic and osteoporosis screening
Vaccination - annual flu
```
Lifestyle:
- avoid smoking
- avoid jacuzzi's
- avoid other people with CF or those with cold's
- clean and dry nebulisers fully
- NaCl tablets in hot weather
96
What causes pleural effusions?
Exudative - protein >35 - infections, inflammation, malignancy
Transudative - protein <25:
- high venous pressure - heart failure, fluid overload, constrictive pericarditis
- low protein - Cirrhosis, nephrotic syndrome, malabsorption
- other - hypothyroid, PE, meig's syndrome (ovarian fibroma)
97
How are pleural effusions managed?
Exudative - drain
Transudative - manage underlying cause
98
If the protein level of a pleural effusion is between 25-35, what do you do?
Use LIGHT's criteria to determine whether it is an exudate or not:
- pleural fluid:serum protein ratio >0.5
- pleural fluid:serum LDH ratio >0.6
- pleural fluid LDH >2/3 of the normal
99
How are pleural effusions investigated?
PA CXR
USS
Contrast CT
Pleural fluid aspiration
100
What would low glucose in a pleural effusion indicate?
Rheumatoid arthritis
| TB
101
What would raised amylase in a pleural effusion indicate?
Pancreatitis
| Oesophageal perforation
102
What would heavy blood staining in a pleural effusion indicate?
Mesothelioma
TB
PE
103
How should pleural effusions be managed?
Turbid/cloudy --> drainage
| Clear but pH <7.2 - drain placed
104
How can recurrent pleural effusions be managed?
Recurrent aspiration
Pleurodesis
Indwelling catheter
Drugs to alleviate symptoms
105
What is obstructive sleep apnoea?
Intermittent closure of the pharyngeal airway causing apnoea episodes when sleeping.
106
What can cause obstructive sleep apnoea?
Already small pharynx:
- fatty infiltration/fat pressure
- Large tonsils
- Craniofacial abnormalities
- Macroglossia - hypothyroid, acromegaly, amyloidosis
Excessive narrowing:
- Neuromuscular disease
- Muscle relaxants
- Excessive
107
How does obstructive sleep apnoea present?
```
Obese middle aged men
Loud snoring
Daytime tiredness
Morning headache
Loss of libido
Nocturia
```
Can cause hypertension and compensated respiratory acidosis
108
How is obstructive sleep apnoea diagnosed?
Night time pulse ox
Video recordings
Polysomnography
109
What scoring system is used for obstructive sleep apnoea?
Epworth sleepiness scale
| Multiple sleep latency test
110
How is obstructive sleep apnoea managed?
Lifestyle - weight loss and decrease alcohol before bed
CPAP
Mandibular advancement device
Surgery
Inform DVLA if excessive daytime tiredness
111
What are the types of pneumothorax?
Primary - no lung disease
Secondary - underlying lung pathology
Iatrogenic
Tension
112
What are some risk factors for pneumothorax?
```
Lung disease
Tall
Smoking cannabis
Scuba diving
Trauma
```
113
How is a pneumothorax managed?
Primary:
- Asymptomatic or <2cm - Observe and review in clinic in 2 wks or needle aspirate
- Symptomatic or >2cm air rim - Chest drain
Secondary:
- >50yo and symptomatic/air rim>2 - chest drain
- air rim 1-2cm - aspirate. drain if fails
- air rim <1cm - O2 and observe
- All pt's admitted for 24hr
114
What guidance is given regarding scuba diving in patients who have had a pneumothorax?
Permanently avoid unless undergone bilateral pleurectomy and normal resp function and CT post op
115
How are iatrogenic pneumothoraxes managed?
Less likely to recur
Most resolve under observation. If not aspirate
Ventilated patients or those with COPD may need a chest drain
116
What is the difference between type 1 and type 2 respiratory failure?
T1 - Low pO2, normal or low pCO2
T2 - Low pO2, high pCO2
T2 due to reduced respiratory drive
117
What are the signs/symptoms of hypoxia?
```
Dyspnoea
Agitation
Restlessness
Confusion
Central cyanosis
```
Long standing --> polycythaemia and pulmonary hypertension
118
What are the signs/symptoms of hypercapnia?
```
Headache
Peripheral vasodilation
Tachycardia
Bounding pulse
CO2 flap
Papilloedema
```
119
How is respiratory failure managed?
Treat underlying cause
Give O2
Assist ventilation
If type 2 - controlled O2 starting at 24%
120
What are the indications for non-invasive ventilation?
- COPD with respiratory acidosis pH 7.25-7.35 (req. HDU if more acidotic)
- T2 resp failure secondary to chest trauma, neuromuscular disease or obstructive sleep apnoea
- Cardiogenic pulmonary oedema unresponsive to CPAP
- Weaning from tracheal intubation
121
What is non-invasive ventilation?
Providing resp. support through sealed face masks, nasal masks, mouth pieces, visors etc. without intubating.
Can be CPAP, BiPAP or Negative pressure
122
How do obstructive and restrictive patterns appear on lung function tests?
Obstructive: Normal FVC, FEV1:FVC <0.7
Restrictive: FVC low, FEV1:FVC >0.7
123
What does an anion gap show?
If increased - increased acid production/ingestion metabolic acidosis (DKA, lactic acidosis, aspirin OD)
If reduced - reduced acid excretion (GI loss of bicarb in diarrhoea), addison's
124
What is allergic bronchopulmonary aspergillosis?
Allergy to aspergillus spores - usually on background of bronchiectasis and eosinophilia
125
What are the features of bronchopulmonary aspergillosis?
Bronchoconstriction - wheeze, cough, dysnpnoea
Proximal bronchiectasis
126
How would you investigate allergic bronchopulmonary aspergillosis?
```
FBC - eosiniphilia
CXR
RAST test - positive for aspergillus
IgG precipitins - increased
Increased IgE
```
127
What imaging changes are seen in allergic bronchopulmonary aspergillosis?
CXR:
- Ring shadowing and tram track opacificties --> bronchiectasis
- Hilar mass
CT:
- Branching lesion with finger in glove appearance - bronchocoele
128
How is allergic bronchopulmonary aspergillosis managed?
Oral glucocorticoids
| Itraconazole 2nd line
129
What are the types of altitude related disorders?
Acute motion sickness
High altitude pulmonary oedema
High altitude cerebral oedema
All due to chronic hypobaric hypoxia
130
How does acute motion sickness present?
Headache, nausea, fatigue when over 2500-3000m
Develop over 6-12hr and last a few days
Self-resolve
131
How can acute motion sickness be managed?
Descent
Don't climb by more than 500m per day
Can give prophylactic acetazolamide
Risk is associated with physical fitness
132
When do high altitude pulmonary/cerebral oedema develop? How do they present?
Over 4000m
HAPE - classic pulmonary oedema
HACE - headache, ataxia, papilloedema
133
How are high altitude pulmonary/cerebral oedema managed?
Descent
HAPE - Nifedipine, dexamethasone, acetazolamide, phosphodiesterase V inhibitors, O2
HACE - dexamethasone
134
What are some differentials for cavitating lung lesions on chest X-ray?
```
Abscess
TB
PE
Squamous cell cancer
Asbestosis
Wegners granulomatosis
Rheumatoid arthritis
Aspergillosis, histoplasmosis
```
135
What can cause lung collapse? What signs are seen on CXR?
```
Common:
- Lung cancer
- Asthma
- Foreign body
CXR:
- Tracheal deviation and mediastinal shift to side of collapse
- Elevated hemi-diaphragm
```
136
What commonly causes lung metastases?
```
Breast
Colorectal
Renal
Bladder
Prostate
```
137
How do renal cell cancers that metastasise to the lungs present?
Cannonball metastases
Can also occur secondary to choriocarcinoma and prostate cancer
138
Which lung metastases may show calcification?
Chondrosarcoma
| Osteosarcoma
139
What can cause mediastinal widening?
```
Vascular problems - thoracic aorta aneurysm
Lymphoma
Retrosternal goitre
Teratoma
Tumour of thymus
```
140
What are the signs of pulmonary oedema on chest xray?
```
Interstitial oedema
Batwing appearance
Kerly B lines
Cardiomegaly
Pleural effusions
```
141
Give some causes of clubbing
```
Cardiac:
- Cyanotic congenital heart defects
- Bacterial endocarditis
- Atrial myxoma
Respiratory:
- Lung cancer
- Pyogenic lesions - CF, bronchiectasis, empyema, abscess
- TB
- Asbestosis/mesothelioma
- Fibrosing alveolitis
```
Others - graves, Crohn's, cirrhosis
142
What happens in coal workers pneumoconiosis?
Coal dust inhaled and enter terminal bronchi. Enguled by alveolar and interstitial macrophages. Normally removed by mucocilliary escalators.
In chronic exposure, system overwhelmed and start to accumulate in alveoli and cause inflammatory damage
143
How does coal workers pneumoconiosis present?
Simple - asymptomatic, increased risk of COPD
Progressive massive fibrosis:
- round fibrotic masses in upper zones
- mixed obstructive/restrictive picture
- breathlessness on exertion
- cough - productive (black)
144
How is coal workers pneumoconiosis managed?
Avoid coal dust and other irritates (smoking)
Manage chronic bronchitis
May be eligible for compensation under industrial injuries act
145
What is Churg-Strauss syndrome?
Eosinophilic granulomatosis and polyangitis
ANCA associated small-medium vessel vasculitis
146
What are the features of Churg-Strauss syndrome?
```
Asthma
Blood eosinophilia - >10%
Paranasal sinusitis
Mononeuritis multiplex
pANCA positive - 60%
```
147
How does Churg-Strauss syndrome vary with Wegeners granulomatosis?
CS is eosinophilic and associated with pANCA
W is associated with cANCA, renal failure and epistaxis
Wegeners associated with glomerulonephritis, saddle shape nose deformity
148
What are the features of wegeners granulomatosis?
```
Upper RT - epistaxis, sinusitis
Lower RT - dysnpnoea, haemoptysis
Rapidly progressive glomerulonephritis
Saddle nose deformity
Vasculitic rash, eye involvement, CN lesions
```
149
How would you investigate wegeners granulomatosis?
cANCA - >90%
CXR - multiple presentations - caveatting lung lesions
Renal biopsy - epithelial crescents on bowman's capsule
150
How is wegeners granulomatosis managed?
Steroids
Cyclophosphamide (90% response)
Plasma exchange
Survival 8-9 years
151
What is kartageners syndrome?
Dextrocardia
Recurrent sinusitis
Bronchiectasis
Subfertility - sperm dysmotility
152
What are the features of klebsiella pneumonia?
Red currant jelly sputum
Common in alcoholics and diabetics
May occur after aspiration
Upper lobes
Commonly causes lung abscess and empyema
153
What shifts the oxygen dissociation curve to the right?
Acidosis
High temperature
Raised 2,3-DPG
154
What can salicylate poisoning cause?
Mixed metabolic acidosis and respiratory alkalosis
Early stimulation of resp. centre --> resp alkalosis
Later the effects of salicylate + renal failure --> metabolic acidosis
155
What is the centor criteria?
Tonsillar exudate
Fever >38
No cough
Tender cervical lymphadenopathy
156
How long do respiratory tract infections tend to last?
```
Otitis media - 4 days
Sore throat/tonsilitis/pharyngitis - 7 days
Common cold - 1.5 weeks
Rhinosinusitis - 2.5 weeks
Cough/bronchitis - 3 weeks
```
157
What are some respiratory manifestations of rheumatoid arthritis?
```
Pulmonary fibrosis
Pleural effusion
Pulmonary nodules
Bronchiolitis obliterans
Complications of drug therapy
Pleurisy
Caplan's syndrome - fibrotic lung nodules
Infection secondary to immunosuppression
```
158
How is smoking cessation managed?
Offer nicotine replacement therapy, varenicline or bupropion
Have a target stop date
Max 2 weeks after stop date
Don't offer again within 6 months if fails
159
How is nicotine replacement therapy given in those with high level of dependence?
Offer NRT patch and one other form of nicotine (gum, inhalator, lozenge, nasal spray)
160
What can be offered for smoking cessation in pregnancy?
Only nicotine replacement therapy
Varenicline and Bupropion contraindicated
161
Which conditions can increase transfer factor?
```
Asthma
Pulmonary haemorrhage
Left and right cardiac shunts
Polycythaemia
Hyperkinetic states
Male
Exercise
```
162
Which conditions reduce transfer factor?
```
Pulmonary fibrosis
Pneumonia
PE
Pulmonary oedema
Emphysema
Anaemia
Low cardiac output
```
163
When in COPD is BiPAP indicated?
Respiratory acidosis with low pO2
