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Royal College Exam > Respirology > Flashcards

Respirology Flashcards

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1
Q

What is a positive methacholine challenge?

A

PC20<4 mg/mL (FEV1 drops by 20% at a methacholine concentration less than 4).

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2
Q

What are the 5 steps in pharmacologic management of asthma?

A
  1. ICS-LABA prn
  2. ICS standing with SABA prn
  3. ICS/LABA standing with SABA prn
  4. ICS/LABA standing and prn OR medium dose ICS/LABA standing and SABA prn.
  5. Tiotropium, macrolides (r/o NTM and bronchiectasis), oral steroids, omalizumab (IgE 30-700), mepolizumab (eosinophils > 300)
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3
Q

What three conditions are treated well with LTRAs?

A

Aspirin-induced asthma, exercise-induced asthma, allergic rhinitis.

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4
Q

What is Samter’s triad?

A

Asthma, nasal polyps, sensitivity to ASA/NSAIDs.

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5
Q

How do you treat ABPA?

A

Prednisone +/- itraconazole.

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6
Q

How do you diagnose severe COPD?

A

COPD - post-bronchodilator FEV/FVC<70%.

Severe - FEV1<50%.

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7
Q

Name three interventions that have mortality benefit for COPD?

A

Smoking cessation, pulmonary rehabilitation, home O2 (PaO2<55 or <60 if hct >56%, MPAP>20 mmHg, bilateral edema).

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8
Q

Name two new recommendations from the CTS 2019 COPD guidelines?

A
  1. Stress importance of screening women in developed countries for COPD due to exposures to smoke and biomass fuel.
  2. Everyone gets screened for a1AT upon COPD diagnosis.
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9
Q

What are the two GOLD criteria for COPD stratification?

A

mMRC breathlessness scale >1 and 2+ exacerbations/year or 1+ exacerbations/year requiring hospitalization.

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10
Q

What are the indications for inhaled corticosteroid therapy in COPD?

A

Symptoms or exacerbations while on LAMA/LABA, peripheral eosinophils>300.

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11
Q

After starting triple therapy, which three add-on interventions reduce COPD exacerbations?

A

Roflumilast, azithromycin, NAC.

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12
Q

Who is a candidate for home BiPAP for COPD?

A

Chronic daytime pCO2>52 and at least 1 hospitalization for acute respiratory failure in the past year.

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13
Q

Ten treatment options for bronchiectasis.

A

Airway clearance, pulmonary physiotherapy, vaccines, bronchodilators, home O2, chronic antibiotics, mucolytics (DNAse only for CF, hypertonic saline), BiPAP, resection for local disease, transplant.

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14
Q

What four conditions must be ruled out before diagnosing interstitial pulmonary fibrosis?

A
  1. CTD (RA, DM, SS, sjogren’s MCTD).
  2. Drugs and radiation (MTX, amiodarone, Macrobid, bleomycin, checkpoint inhibitors).
  3. Hypersensitivity pneumonitis (mould, water, birds).
  4. Pneumoconioses (asbestos, silicosis).
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15
Q

What are the radiographic features of UIP?

A

Reticular changes, honeycombing, subpleural, basal predominant, absence of inconsistent features (nodules, consolidation, ground glass opacities, cysts).

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16
Q

What is suggestive of an IPF exacerbation?

A

CT chest showing new ground glass opacities on top of chronic UIP pattern, worsening dyspnea, hypoxemia.

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17
Q

Name 6 causes of exudative pleural effusion.

A

Malignancy, parapneumonic effusion, tuberculosis, benign asbestos effusion, rheumatoid arthritis, pulmonary embolism.

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18
Q

What are the most sensitive and specific findings for exudative effusion?

A

Sensitive: all three Light criteria absent.
Specific: cholesterol level>55mg/dL, LDH>200, pleural/serum cholesterol>0.3.

19
Q

What causes a low pleural glucose (<3 or pleural/serum <0.5)?

A

<3 - malignancy, TB, lupus.

<1 - rheumatoid arthritis, empyema.

20
Q

What size primary pneumothorax requires chest tube insertion?

A

> 2 cm.

21
Q

What are the features of Heerfordt’s syndrome?

A

Anterior uveitis, parotid enlargement, facial palsy, fever.

22
Q

What are the three organs that can cause life-threatening sarcoidosis and how would you work them up?

A

Ocular - anterior uveitis, refer to ophtho if symptoms.
Neurologic - CN palsy, MRI brain.
Cardiac - new block or cardiomyopathy, screen with ECG, refer for cMRI if abnormal.

23
Q

How do you diagnose obstructive sleep apnea?

A

Symptoms (sleepiness, choking, awakenings) and objective testing (>5 apnea/hypopnea events during sleep monitoring).

24
Q

What conditions are associated with type 1 pulmonary hypertension?

A

HIV, CTD, portal hypertension, schistosomiasis.

25
Q

What is the calculation and normal range for the A-a gradient?

A

A-a = 150 - 1.25 x pCO2 - pO2.

A-a > age/4 + 4 is abnormal.

26
Q

What are follow up guidelines for single, low risk pulmonary nodule?

A

< 6mm, no follow up.

6-8mm, CT at 6-12 months then repeat a year later

> 8mm, CT at 3 months +/- PET +/- bx

27
Q

What are the radiologic findings of NSIP?

A

Ground glass opacities, reticular changes, traction bronchiectasis, no honeycombing.

28
Q

What three tests are specific for clubbing?

A

Interpalyngeal depth ratio > 1.0 (DPD/IPD), Lovebond’s angle > 176, hyponychial angle > 192.

29
Q

What does variable extrathoracic obstruction look like on PFT and what causes it?

A

Flat inspiratory (lower) curve, vocal cord dysfunction.

30
Q

What does variable intrathoracic obstruction look like on PFT and what causes it?

A

Flat expiratory (upper) curve, tracheomalacia

31
Q

What does fixed upper airway obstruction look like on PFT and what causes it?

A

Both curves flat, Wegner’s, sarcoid, polychondritis.

32
Q

Name 4 causes of isolated reduced DLCO.

A

Early ILD, early empyema, pulmonary hypertension, anemia.

33
Q

What are 4 contraindications to methacholine challenge?

A
  1. FEV1<50% or <1L
  2. Recent MI or stroke in past 3 months
  3. BP>200/100
  4. Known aortic aneurysm
34
Q

What are risk factors for primary pneumothorax?

A

Smoking
Family history
Marfan syndrome
Thoracic endometriosis

35
Q

When should you step down therapy for asthma?

A

symptom control x 2 months and low risk of exacerbations.

36
Q

What are causes of high pleural fluid eosinophilia?

A 
Abestos
drugs (nitrofurantoin)
malignancy
infection (parasitic)
PE
eGPA
37
Q

What workup should you obtain for everyone for bronchiectasis?

A 
PFT, Chest CT
CBC, IgE, serum immunoglobulins
Sweat chloride test
Nasal nitric oxide
Sputum cultures
38
Q

What are indications for chest drain for parapneumonic effusions?

A

Drainage of frank pus/cloudy
positive gram stain/culture
pH < 7.2, or glucose < 3.4
> 50% of hemithorax or loculation on imaging

39
Q

What are causes of pleural fluid lymphocytosis?

A

TB vs lymphoma most common

Carcinoma, sarcoidosis, RA, yellow nail syndrome also possible

40
Q

When should take away drivers license for someone with OSA?

A

Need one of:

Excessive sleepiness during major wake periods while driving

Crash associated with falling asleep in the last 5 years if not on effective therapy

Non compliant with therapy

41
Q

What are follow up guidelines for single, high risk pulmonary nodule?

A

< 6mm May warrant repeat CT
6-8mm CT 6-12 months, the repeat at 2yr
>8mm CT at 3 month, PET/CT or bx

42
Q

What are causes of upper lobe ILD?

A

HASTEN

Hypersensitivity pneumonitis
Ankylosing spondylitis
Sarcoidosis, silicosis
TB
Eosinophilic granulomas
Neurofibromatosis
43
Q

What are causes of lower lobe ILD?

A

BAD RASH

Bleomycin
Amiodarone
Drugs (methotrexate, cyclophosphamide, macrobid)
Rheumatoid lung
Asbestosis/Aspiration
Scleroderma
Hamman-Rich syndrome (idiopathic pulmonary fibrosis)

44
Q

What is silica exposure associated with?

A

TB, lung cancer, fibrosis, RA, airflow limitation

Royal College Exam (15 decks)

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