Respiratory Corrections 3 Flashcards
What appearance of the lung tissue is seen on a high-resolution CT scan in pulmonary fibrosis? (1)
‘Ground glass’ appearance
What is the characteristic histology finding in sarcoidosis? (1)
Non-caseating granulomas with epithelioid cells
What electrolyte abnormality is commonly seen in sarcoidosis? (1)
Hypercalcaemia
How does sarcoidosis cause hypercalcemia?
Due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 by macrophages (i.e. active form of vitamin D).
Active form of vitamin D results in an increased absorption of calcium in the intestine.
What is the test of choice for diagnosing bronchiectasis? (1)
High resolution CT (HRCT)
What is the normal PaO2 of arterial blood? (1)
10.7-13.3 kPa
What is the initial medical management of a massive pulmonary embolism with haemodynamic compromise? (2)
1) Continuous infusion of UH
2) Consider thrombolysis with alteplase
What type of atypical pneumonia may be contracted from infected birds, including parrots? (1)
Chalmydia psittaci
What classes of medication can be used to treat pulmonary hypertension? (4)
1) Calcium channel blockers
2) PDE-5 inhibitors e.g. sildenafil
3) IV prostaglandins e.g. epoprostenol
4) Endothelin receptor antagonists e.g. macitentan
What is used as a screening blood test for sarcoidosis? (1)
Serum ACE (angiotensin converting enzyme)
What is a serum marker that is increased in sarcoidosis?
ACE
Why is ACE raised in sarcoidosis?
ACE is produced by the epithelioid cells that are derived rom recently-activated macrophages in granulomas.
What nerve palsy in a patient with lung cancer causes diaphragm weakness and worsened shortness of breath? (1)
Phrenic nerve palsy
What scoring system is used to assess sleepiness associated with obstructive sleep apnoea? (1)
Epworth sleepiness scale
What is targeted and damaged in patients with Lambert-Eaton myasthenic syndrome? (3)
What type of lung cancer is this associated with? (1)
What is the main presenting feature of this syndrome? (1)
Voltage gated calcium channels on the PRE-synaptic terminals of MOTOR neurones.
Small cell lung cancer
Proximal muscle weakness
What two medications are licensed for slowing disease progression in idiopathic pulmonary fibrosis? (2)
1) Pirfenidone
2) Nintedanib
Why might a patient with lung cancer develop a hoarse voice? (1)
tumour pressing on the recurrent laryngeal nerve
What can determine whether obstructive lung disease is caused by COPD or asthma during routine lung function tests? (1)
Reversibility testing (obstruction is reversible in asthma but not COPD)
What is the name for minimally invasive “keyhole” surgery to treat lung pathology, such as cancer? (1)
Video assisted thoracoscopic surgery (VATS)
What 2 specific medication options are recommended first-line for treating a pulmonary embolism in stable patients?
Apixaban
Rivaroxaban
What is the normal PaCO2 of arterial blood? (1)
4.7-6.0 kPa
What is the triad of features of yellow nail syndrome? (3)
1) Yellow, hard nails
2) Lymphoedema
3) Bronchiectasis
What term describes the volume of air pushed in per breath during mechanical ventilation? (1)
Tidal volume
How might lung cancer cause hypercalcaemia? (2)
1) Ectopic production of PTHrP by squamous cell carcinoma
2) Bone mets
What point of care test may be used in primary care to indicate whether a patient presenting with features of a lower respiratory tract infection will benefit from antibiotics? (1)
CRP
What type of atypical pneumonia is most associated with hyponatraemia? (1)
Legionella pneumophila
What are the top causes of transudative pleural effusions? (4)
1) HF
2) Hypoalbuminaemia
3) Meig’s syndrome
4) Hypothyroidism
What is the usual first-line medication for treating sarcoidosis? (1)
Oral steroids
What tool can be used when the clinician estimates less than a 15% probability of a pulmonary embolism to decide whether further investigations for a PE are needed? (1)
PERC rule (PE rule out criteria)
What genetic condition may be tested for in a non-smoker with early-onset COPD? (1)
What is the screening test for this? (1)
Alpha-1 antitrypsin deficiency
Serum alpha-1 antitrypsin
What investigation is required before initiating NIV (other than ABGs)? (1)
CXR
What is the usual duration of antibiotics in patients with an infective exacerbation of bronchiectasis? (1)
7-14 days
What antibodies are linked with limbic encephalitis as a paraneoplastic syndrome associated with lung cancer? (1)
Anti-Hu antibodies
What are the indications for long-term oxygen therapy in severe COPD? (4)
What is the most common contraindication? (1)
Indications:
1) Chronic hypoxia (SpO2 <92%)
2) Polycythaemia
3) Cyanosis
4) Cor pulmonale
Contraindication –> Smoking
Who should LTOT be offered to in COPD?
1) Patients with a pO2 of <7.3 kPa
or
2) Those with a pO2 of 7.3-8 kPa AND one of:
a) 2ary polycythaemia
b) peripheral oedema
c) pulmonary HTN
What is the second-line medical treatment of COPD where there are no asthmatic or steroid-responsive features?
SABA as required
LABA + LAMA
What type of fungal pneumonia typically occurs in immunocompromised patients, such as those with end-stage HIV? (1)
What medication may be taken prophylactically in patients at risk of this condition? (1)
Pneumocystic jirovecii pneumonia (PCP)
Co-trimoxazole (trimethorpim + sulfamethoxazole)
What blood test finding is an indication for urgent investigation for lung cancer? (1)
Thrombocytosis
What common classes of medication worsen the symptoms of asthma? (2)
NSAIDs & beta blockers
What scale can be used for rating breathlessness in a patient with COPD? (1)
MRC Dyspnoea Scale (medical research council)
What sites are options for inserting a large bore cannula for emergency management of a tension pneumothorax? (2)
1) 2nd intercostal space in midclavicular line
2) 4th or 5th intercostal space anterior to the midaxillary line
What is the meaning of FiO2? (1)
Fraction of inhaled O2 (the O2 concentration of the inhaled gas)
What complications is obstructive sleep apnoea strongly associated with?
CVS complications e.g. stroke, coronary artery disease, AF, HF and T2DM.
Depression.
Work-related injuries.
RTCs.
What is the next step in patients with a solitary pulmonary nodule ≥8mm if the patient is fit for surgery?
CT guided percutaneous transthoracic needle aspiration biopsy (TTNB)
What is the next step in patients with a solitary pulmonary nodule ≥8mm if the patient is NOT fit for surgery?
Serial CT imaging for 2 years
What is the next step in patients with a solitary pulmonary nodule <4mm in size?
Serial CT imaging for 2 years
What is the next step in patients with a solitary pulmonary nodule <3mm in size?
Observation with no further workup
High resolution CT findings in idiopathic pulmonary fibrosis? (3)
1) honeycombing
2) traction bronchiectasis
3) bibasilar reticular opacities
Radiological findings in PCP?
Bilateral interstitial infiltrates
What is P pulmonale ?
Right atrial abnormality seen on ECG as tall, peaked P waves
What does P pulmonale indicate?
Pulmonary HTN (cause of right atrial enlargement)
What are some causes of ARDS? (7)
1) Pneumonia
2) Sepsis
3) Aspiration
4) Pancreatitis
5) Transfusion reactions (TRLI)
6) Trauma & fractures
7) Fat embolism
Signs & symptoms of ARDS?
- Severe SOB
- Tachypnoea
- Confusion
- Presyncope
Exam:
- Fine bibasal crackles but NO other features of HF
Management of ARDS?
Supportive:
- Low tidal volume mechanical ventilation
- Haemodynamic support to maintain mean arterial pressure >60 mmHg
- DVT prophylaxis
- Nutritional support
1st line immediate management of SVCO?
Oral dexamethasone
Which type of pneumonia is also associated with herpes?
Strep. pneumoniae
Does RA cause lung fibrosis in the lower or upper zones?
Lower zones
Name 2 drugs that cause lower zone lung fibrosis
Methotrexate & bleomycin
Can recurrent lung abscesses cause clubbing?
Yes
What are 4 indications for lung reduction surgery in chronic COPD?
1) they have upper lobe predominant emphysema
2) FEV1 >20% predicted
3) paCO2 <7.3 kPa
4) TLCO >20% predicted
What dermatological manifestation is mycoplasma pneumoniae associated with?
Erythema multiforme
Describe erythema multiforme
Multiple erythematous papules with deeply erythematous borders
Mx of COPD exacerbation?
1) O2 sats, aiming for 88-92%
2) Salbutamol via inhaler or nebuliser (dependent on severity)
3) Muscarinic antagonist (e.g. tiotropium or ipratropium) via inhaler or nebuliser
4) Corticosteroid e.g. oral pred
5) Abx for potential infection
How can severe obesity affect lung function tests?
Can cause restrictive picture
How is gas transfer in lungs affected in severe obesity vs idiopathic pulmonary fibrosis?
Severe obesity: normal
IPD: reduced
What FeNO criteria is diagnostic of asthma?
Exhaled FeNO of ≥40 parts per billion
What post-bronchodilator improvement is diagnostic of asthma? (2)
1) Improvement in FEV1 ≥12%
2) Improvement in lung volume of 200ml
What is the most common form of asbestos-related lung disease?
Pleural plaques
1st line management of HAP?
Co-amoxiclav
What condition are ‘cannonball mets’ in the lungs most commolny associated with?
What investigation would you then get?
Renal cell cancer
CT abdomen
3 aspects of discharge advice following a pneumothorax?
1) Smoking cessation
2) Fitness to fly –> can fly 1 week post check XR
3) Scuba diving –> permanently avoid
How is a definitive diagnosis of mesothelioma made?
Thoracoscopy followed by histology
A suspicious lung mass is found on a chest X-ray.
What investigation is most appropriate next?
Contrast enhanced CT scan (of chest, liver and adrenals)
Why is a contrast CT scan used in investigating lung cancer over a non-contrast CT?
Non-contrast CT is less accurate
What test is diagnostic for OSA?
Polysomnography (PSG)
What Abx is indicated as prophylaxis to reduce the frequency of COPD exacerbations (in those that meet the criteria)?
Azithromycin
What investigation should be done prior to starting azithromycin?
Why?
ECG - as azithromycin can cause QT prolongation
Role of PDE-4 inhibitors (e.g. roflumilast) in COPD?
Reduce the risk of COPD exacerbations in patients with severe COPD and a history of frequent COPD exacerbations
What is extrinsic allergic alveolitis (EAA), also known as hypersensitivity pneumonitis?
A condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles.
Give some examples of extrinsic allergic alveolitis (4)
1) bird fanciers’ lung: avian proteins from bird droppings
2) farmers lung: spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
3) malt workers’ lung: Aspergillus clavatus
4) mushroom workers’ lung: thermophilic actinomycetes*
Management of extrinsic allergic alveolitis?
Mainly avoidance of triggers
Presentation of extrinsic allergic alveolitis?
acute (occurs 4-8 hrs after exposure)
- dyspnoea
- dry cough
- fever
chronic (occurs weeks-months after exposure)
- lethargy
- dyspnoea
- productive cough
- anorexia and weight loss
Does coal workers’ pneumoconiosis typically cause upper or lower zone fibrosis?
Upper
How should asthma drugs be adjusted in pregnancy?
Keep the same! Importance of good asthma control
What condition may a calcified Ghon complex be seen on a CXR?
Latent TB
Which type of pneumonia is particularly associated with diabetic and alcoholic patients?
Klebsiella pneumonia
What type of pneumonia causes a cavitating pneumonia in the upper lobes?
Klebsiella
What is the management plan for latent TB?
3 months of isoniazid (with pyridoxine) and rifampicin, or
6 months of isoniazid (with pyridoxine)
What vaccinations are women offered during pregnancy?
Pertussis (16-32 weeks) and influenza
