Week 8 - Respiratory

Question 1

What are 7 reasons why we measure lung function?

Answer 1

1. Evaluation of breathless patient
2. Screening for COPD/ occupational lung disease
3. Lung cancer- fitness for treatment
4. Pre-operative assessment
5. Disease progression & treatment response
6. Monitoring drug treatment toxic to lungs
7. Pulmonary complications of systemic disease

Question 2

What 2 lung function tests can we measure at home?

Answer 2

1. Peak flow

2. Oximetry

Question 3

What 2 lung function tests can we measure at the GP surgery?

Answer 3

1. Spirometry

2. Oximetry

Question 4

What 7 lung function tests can we measure in a specialist lab?

Answer 4

1. Spirometry
2. Transfer factor
3. Lung volumes
4. Blood gases
5. Bronchial provocation testing
6. Respiratory muscle function
7. Exercise testing

Question 5

What is spirometry?

Answer 5

Forced expiratory manoeuvre from total lung capacity followed by a full inspiration (best of 3)

Question 6

What are the 4 pitfalls to spirometry?

Answer 6

1. Appropriately trained technician
2. Effort & technique dependent
3. Patient frailty
4. Pain, patient too unwell

Question 7

What are 5 lung functions that can be directly measured?

Answer 7

1. VC (vital capacity)
2. IC (inspiratory capacity)
3. IRV (inspiratory reserve volume)
4. VT (normal tidal breathing)
5. ERV (expiratory reserve volume)

Question 8

What are 3 lung functions that can be indirectly measured?

Answer 8

1. RV (residual volume)
2. TLC (total lung capacity)
3. FRC (functional residual capacity)

Question 9

What 4 things can a time/volume plot measure?

Answer 9

1. PEFR (peak expiratory flow rate)
2. FEV1
3. FVC
4. FEV1/ FVC ratio (normal >70%)

Question 10

What is a “normal” % of FEV1?

Answer 10

85% predicted

Question 11

What 5 things should you correct for in FEV1 reference ranges?

Answer 11

1. Age
2. Gender
3. Race
4. Height
5. Atmospheric values

Question 12

What is obstructive lung disease generally?

Answer 12

Asthma or COPD

Question 13

What is the FEV1/FVC ratio for obstructive lung disease?

Answer 13

<70%

Question 14

Describe how the severity of COPD is stratified by % predicted FEV1?

Answer 14

• Mild >80%
• Mod 50-80%,
• Severe 30-50%,
• Very severe <30%

Question 15

Describe reversibility testing?

Answer 15

• Nebulised or inhaled salbutamol given

- Spirometry before & 15 min after salbutamol

Question 16

What reversibility testing result is suggestive to asthma?

Answer 16

15% AND 400ml reversibility in FEV1

Question 17

What are 4 investigations for asthma?

Answer 17

1. PEFR testing
2. Bronchial provocation
3. Spirometry before & after trial of inhaled/ oral corticosteroid
4. Reversibility testing

Question 18

Describe PEFR testing for asthma?

Answer 18

• Look for diurnal variation & variation over time
• Response to inhaled corticosteroid
• Occupational asthma

Question 19

Describe the lung test results for restrictive lung disease?

Answer 19

• FEV1 AND FVC reduced

- FEV1/ FVC ratio >70%

Question 20

What are 6 causes of restrictive spirometry?

Answer 20

1. Interstitial lung disease (stiff lungs)
2. Kyphoscoliosis/ chest wall abnormality
3. Previous pneumonectomy
4. Neuromuscular disease
5. Obesity
6. Poor effort/ technique

Question 21

What are the 4 stages to interpreting spirometry?

Answer 21

1. Look at FEV1/ FVC ratio (if <70%, obstruction)
2. If obstructed, look at % predicted FEV1 (severity) & any reversibility (COPD vs asthma)
3. If FEV1/ FEV ratio normal, look at % predicted FVC (if low, suggests restrictive abnormality)
4. Can also get mixed picture (obesity & COPD)

Question 22

Describe the transfer factor (TLCO, KCO, DLCO)?

Answer 22

• Single breath of a very small concentration of carbon monoxide
• CO has very high affinity to Hb
• Measure concentration in expired gas to derive uptake in the lungs

Question 23

What 4 things is transfer factor affected by?

Answer 23

1. Alveolar surface area
2. Pulmonary capillary blood volume
3. Haemoglobin concentration
4. Ventilation perfusion mismatch

Question 24

What 4 things is transfer factor reduced in?

Answer 24

1. Emphysema
2. Interstitial lung disease
3. Pulmonary vascular disease
4. Anaemia (increased in polychthaemia)

Question 25

What are you unable to measure by spirometry?

Answer 25

Residual volume

Question 26

What are the 2 methods of measuring lung volumes?

Answer 26

1. Helium dilution (inspire known quantity of inert gas) 2. Body plethysmography (respiratory manoevures in a sealed box lead to changes in air pressure- can derive lung volumes. Archimedes principle!)

Question 27

When is lung volumes reduced?

Answer 27

Restrictive lung disease

Question 28

When is RV & RV/TLC increased?

Answer 28

Obstructive lung disease

Question 29

What is oximetry?

Answer 29

Non-invasive measurement of saturation of haemoglobin by oxygen

Question 30

What does oximetry depend on?

Answer 30

- Oxyhaemoglobin & deoxyhaemoglobin absorbing infrared light differently - Adequate perfusion (shock, cardiac failure)

Question 31

What does oximetry NOT measure?

Answer 31

Carbon dioxide (so not ventilation)

Question 32

What is the main downfall of oximetry?

Answer 32

False reassurance in a patient on oxygen with normal saturations (acute asthma, COPD, hypoventilation)

Question 33

What are the 4 main causes of hypoxaemia?

Answer 33

1. Hypoventilation (eg drugs, neuromuscular disease) 2. Ventilation/ perfusion mismatch (eg COPD, pneumonia) 3. Shunt (eg congenital heart disease) 4. Low inspired oxygen (altitude, flight)

Question 34

Describe ventilation perfusion mismatch?

Answer 34

- Happens to a degree in normal lungs - Main cause of hypoxaemia in medical patients - Areas of lung that are perfused but not well ventilated (eg pneumonic consolidation)

Question 35

What causes hypoxaemia?

Answer 35

Mixing of blood from poorly ventilated & well ventilated parts of the lung

Question 36

What doesn't fully correct with oxygen administration?

Answer 36

Ventilation perfusion mismatch

Question 37

What is an extreme form of V/Q mismatch?

Answer 37

Shunt

Question 38

What is the pO2 & pCO2 of air?

Answer 38

- pO2 = 21 kPa | - pCO2 = 0.03 kPa

Question 39

What is the alveolar oxygen equation?

Answer 39

PAO2 = FiO2 – (1.25 x PaCO2)

Question 40

What is PAO2?

Answer 40

Alveolar oxygen partial pressure, kPa

Question 41

What is FiO2?

Answer 41

Inspired oxygen concentration, kPa

Question 42

How can Arterial pO2 (PaO2) be measured?

Answer 42

Directly measured- ABG

Question 43

What is the difference between calculated alveolar pO2 & the arterial pO2?

Answer 43

The alveolar arterial (A-a) oxygen gradient

Question 44

What should the difference between alveolar & arterial oxygen partial pressure be?

Answer 44

<2-4 kPa (more than this suggests V/Q mismatch)

Question 45

Describe the 3 steps to blood gas analysis from a respiratory perspective?

Answer 45

- Always look at the pO2 first (Is the patient in respiratory failure requiring additional oxygen?) - Look at the PCO2 (type 1 vs type 2 respiratory failure) - Consider acid base balance

Question 46

Describe the blood gas analysis of acute respiratory acidosis (acid base balance)?

Answer 46

- Elevated pCO2 - Normal bicarbonate - Acidosis

Question 47

Describe the blood gas analysis of compensated respiratory acidosis?

Answer 47

- Elevated pCO2 - Elevated bicarbonate (renal compensation) - Not acidotic

Question 48

Describe the blood gas analysis of acute on chronic respiratory acidosis?

Answer 48

- Elevated pCO2 - Elevated bicarbonate - Acidotic

Question 49

Define Chronic Obstructive Pulmonary Disease (COPD)?

Answer 49

Characterised by airflow obstruction which is usually progressive, not fully reversible & does not change markedly over several months

Question 50

What is COPD commonly caused by?

Answer 50

Smoking

Question 51

Only 15-20% of smokers get COPD, so what are 4 other factors which can cause COPD?

Answer 51

1. Environmental pollution 2. Burning of biomass fuels 3. Occupational dusts 4. Alpha 1 anti-trypsin deficiency

Question 52

List the 6 effects of cigarette smoking on the lungs?

Answer 52

1. Cilial motility reduced 2. Airway inflammation 3. Mucus hypertrophy & hypertrophy of Goblet cells 4. Increased protease activity, anti-proteases inhibited 5. Oxidative stress 6. Squamous metaplasia → higher risk of lung cancer

Question 53

Describe alpha 1 antitrypsin deficiency (genetic risk of COPD)?

Answer 53

- Present in 1-3 % of COPD patients - Serine proteinase inhibitor - M alleles normal variant - SS & ZZ homozygotes have clinical disease

Question 54

Describe the 2 part clinical syndrome of COPD?

Answer 54

1. Chronic Bronchitis- production of sputum on most days for at least 3 months in at least 2 years 2. Emphysema- abnormal, permanent enlargement of the airspaces distal to the terminal bronchioles

Question 55

Describe the morphology of chronic bronchitis?

Answer 55

- Loss of interstitial support - Increased epithelial mucous cells - Mucus gland hyperplasia - Squamous metaplasia - Infiltration with neutrophils & CD8+ lymphocytes

Question 56

What does the inflammation in chronic bronchitis lead to?

Answer 56

Scarring & thickening of airway (>4mm in diameter)

Question 57

Describe small airways disease?

Answer 57

- “Bronchiolitis” in airways of 2 -3 mm - May be an early feature of COPD - Narrowing of the bronchioles due to mucus plugging, inflammation & fibrosis

Question 58

List the 3 cell types present in COPD inflammation?

Answer 58

1. Macrophages 2. CD8 & CD4 T 3. Neutrophils

Question 59

List the 4 types of inflammatory markers present in COPD inflammation?

Answer 59

1. TNF, IL-8 & other chemokines 2. Neutrophil elastase, proteinase 3, cathepsin G (from activated neutrophils) 3. Elastase & MMPs (from macrophages) 4. Reactive oxygen species

Question 60

What persists after smoking ceased?

Answer 60

Airway inflammation

Question 61

Describe Centri-acinar Emphysema?

Answer 61

- Damage around respiratory bronchioles | - More in upper lobes

Question 62

Describe Pan-acinar Emphysema?

Answer 62

- Uniformly enlarged from the level of terminal bronchiole distally - Can get large bullae - Associated with α1 anti-trypsin deficiency

Question 63

What does emphysema cause?

Answer 63

Consequent loss of surface area for gas exchange

Question 64

List the 3 types of emphysema?

Answer 64

1. Centriacinar 2. Paraseptal 3. Panacinar

Question 65

List the 4 mechanism of airflow obstruction in COPD?

Answer 65

1. Loss of elasticity & alveolar attachments due to emphysema --> airways collapse on expiration 2. Goblet cell metaplasia with mucus plugging of lumen 3. Inflammation of airway wall 4. Thickening of bronchiolar wall

Question 66

What does loss of elasticity and alveolar attachments due to emphysema cause?

Answer 66

Airway collapse on expiration → Airtrapping & hyperinflaltion → increased work of breathing → breathlessness

Question 67

How do you diagnose COPD?

Answer 67

People who are over 35, & smokers or ex-smokers, with any of: - Exertional breathlessness - Chronic cough - Regular sputum production - Frequent winter ‘bronchitis’ - Wheeze

Question 68

What is the spirometry result for COPD (obstructive lung disease)?

Answer 68

FEV1/FVC ratio < 70 % (both reduced)

Question 69

What are the 5 types of treatment for COPD?

Answer 69

1. Inhaled bronchodilators 2. Inhaled corticosteroids 3. Oral theophyllines 4. Mucolytics - carbocysteine 5. Nebulised therapy

Question 70

What are 2 examples of inhaled bronchodilators used for COPD?

Answer 70

1. Short-acting: salbutamol | 2. Long acting: salmeterol, tiotropium

Question 71

What are 2 examples of inhaled corticosteroids used for COPD?

Answer 71

1. Budesonide & fluticasone: combination inhalers | 2. Oxygen therapy

Question 72

What 2 types of treatment would you give for A type (low risk) COPD?

Answer 72

1. SABA | 2. SAMA

Question 73

What 2 types of treatment would you give for B type (low risk) COPD?

Answer 73

1. LABA or LAMA | 2. LABA + LAMA

Question 74

What 3 types of treatment would you give for C type (high risk) COPD?

Answer 74

1. LAMA 2. LABA + LAMA 3. LABA + ICS

Question 75

What combination of treatments would you give for D type (high risk) COPD?

Answer 75

LABA + LAMA + ICS + theophylline + macrolide

Question 76

List 4 endotypes in the personalised treatment of COPD?

Answer 76

1. Persistent systemic inflammation 2. Eosinophilic or Th2 high COPD 3. Persistent pathogenic bacterial colonisation 4. α-1 antitrypsin deficiency

Question 77

List 3 phenotypes in the personalised treatment of COPD?

Answer 77

1. Frequent exacerbators 2. Persistent breathlessness 3. Chronic bronchitis

Question 78

How is a decline in lung function measured?

Answer 78

Forced expiratory volume in 1 second (FEV1)

Question 79

Describe the symptoms of FEV1 <80% predicted?

Answer 79

Worsening airflow limitation & shortness of breath typically developing on exertion

Question 80

Describe the symptoms of FEV1 <50% predicted?

Answer 80

Increased breathlessness & repeated exacerbations impact patient quality of life & will likely lead to increased hospitalisation

Question 81

Describe the symptoms of FEV1 <30% predicted?

Answer 81

- Severe breathlessness & respiratory failure, marked by hypoxemia - Pulmonary hypertension usually develops following severe hypoxemia

Question 82

What are 2 systemic, extra pulmonary effects of COPD (decreased FEV1)?

Answer 82

1. Systemic inflammation | 2. Skeletal muscle dysfunction

Question 83

What is a blue bloater (respiratory failure in COPD)?

Answer 83

- Low respiratory drive - Type 2 respiratory failure - ↓PaO2, ↑PaCO2

Question 84

List the 7 signs of a blue bloater (respiratory failure in COPD)?

Answer 84

1. Cyanosis 2. Warm peripheries 3. Bounding pulse 4. Flapping tremor 5. Confusion, drowsiness, 6. Right heart failure 7. Oedema, raised JVP

Question 85

What is a pink puffer (respiratory failure in COPD)?

Answer 85

- High respiratory drive - Type 1 respiratory failure - ↓PaO2, ↓PaCO2

Question 86

List the 6 signs of a pink puffer (respiratory failure in COPD)?

Answer 86

1. Desaturates on exercise 2. Pursed lip breathing 3. Use accessory muscles 4. Wheeze 5. Indrawing of intercostals 6. Tachypnoea

Question 87

What does ACOS stand for?

Answer 87

Asthma-COPD overlap syndrome

Question 88

Describe the inflammatory processes involved in asthma?

Answer 88

Sensitising agent --> Asthmatic airway inflammation (CD4+, T lymphocytes, eosinophils) --> Completely reversible

Question 89

Describe the inflammatory processes involved in COPD?

Answer 89

Noxious agent --> COPD airway inflammation (CD8+, T lymphocytes, macrophages, neutrophils) --> Irreversible

Question 90

What is the likely cause if you have >400ml reversibility on spirometry?

Answer 90

Asthma

Question 91

What is the only intervention which slows the progression of COPD?

Answer 91

Smoking cessation

Question 92

List the 4 clinical features of COPD?

Answer 92

1. Nearly all smokers or ex-smokers 2. Rarely get symptoms under 35 years 3. Chronic productive cough 4. Persistent & progressive breathlessness

Question 93

List the 5 clinical features of asthma?

Answer 93

1. Possibly a smoker or ex-smoker 2. Ofter have symptoms under 35 years 3. Variable breathlessness 4. Night time waking with breathlessness &/or wheeze 5. Significant diurnal or day to day variability of symptoms

Question 94

What is respiratory failure defined as?

Answer 94

PO2 <8 kPa at sea level

Question 95

What SpO2 should you aim for in patients with exacerbated COPD?

Answer 95

88-92%

Question 96

What is the normal SpO2 & PaO2 (kPa)?

Answer 96

- SpO2= 95-99% | - PaO2= 10-13.3%

Question 97

What is the mild hypoxaemia SpO2 & PaO2 (kPa)?

Answer 97

- SpO2= 90-95% | - PaO2= 8-10%

Question 98

What is the moderate hypoxaemia SpO2 & PaO2 (kPa)?

Answer 98

- SpO2= 85-90% | - PaO2= 6.7-8%

Question 99

What is the severe hypoxaemia SpO2 & PaO2 (kPa)?

Answer 99

- SpO2= <85% | - PaO2= <6.7%

Question 100

Describe the ABG results of metabolic acidosis?

Answer 100

- Increased H+ - Decreased HCO3 (primary derangement) - Decreased PCO2 (if compensation is present)

Question 101

Describe the ABG results of metabolic alkalosis?

Answer 101

- Decreased H+ - Increased HCO3 (primary derangement) - Increased PCO2 (if compensation is present)

Question 102

Describe the ABG results of respiratory acidosis?

Answer 102

- Increased H+ - Increased PCO2 (primary derangement) - Increased HCO3 (if compensation is present)

Question 103

Describe the ABG results of respiratory alkalosis?

Answer 103

- Decreased H+ - Decreased PCO2 (primary derangement) - Decreased HCO3 (if compensation is present)

Question 104

What is the normal range blood gas analysis of H+?

Answer 104

36-43 nmol/L

Question 105

What is the normal range blood gas analysis of pH?

Answer 105

7.35 – 7.45

Question 106

What is the normal range blood gas analysis of PCO2?

Answer 106

4.6 – 6.0 kPa

Question 107

What is the normal range blood gas analysis of PO2?

Answer 107

10.5 – 13.5 kPa

Question 108

What is the normal range blood gas analysis of actual bicarbonate (calculated)?

Answer 108

23 – 30 mmol/L

Question 109

What is the Henderson-Hasselbalch equation?

Answer 109

pH = pK + log [HCO3- ] / alphaPCO2

Question 110

According to the Henderson-Hasselbalch equation what 3 things have a fixed relationship?

Answer 110

[H+], P CO2 & [HCO3-]

Question 111

What are the 4 questions to ask when assessing ABGs?

Answer 111

1. Acidaemia or Alkalaemia? 2. Primary disturbance: respiratory or metabolic? 3. For a metabolic acidosis, is there a high anion gap? 4. Is there compensation? Appropriate?

Question 112

Describe acid/base compensation?

Answer 112

- Usually partial - Respiratory compensations (to metabolic disorders) happen quickly (mins- hrs) - Metabolic compensations are slower (many hrs-days) - Greater compensation in chronic than acute disorders

Question 113

Is over compensation possible?

Answer 113

NO- look for another abnormality

Question 114

What are the 4 buffers for ABG compensation?

Answer 114

1. Haemoglobin 2. Plasma proteins 3. Bicarbonate 4. Phosphate

Question 115

What are 2 reasons as to why we recognise compensation?

Answer 115

1. Primary disorders with compensation vs mixed disorders | 2. Mild disorders can get fully compensated, but should make you think of mixed disorders

Question 116

Describe compensation?

Answer 116

- Compensatory responses for metabolic disorders are not as predictable as respiratory disorders - The compensation is always in the same direction as the initial chemical change

Question 117

What concurrent acid-base disturbance is impossible?

Answer 117

Concurrent respiratory alkalosis & respiratory acidosis

Question 118

When should you suspect a mixed acid-base disorder?

Answer 118

- Inadequate/too extreme compensation - The pCO2 & HCO3 concentration become abnormal in the opposite direction (one is elevated while the other is reduced) - pH is normal but pCO2 or HCO3 concentration is abnormal

Question 119

What acid-base disturbance is shown in respiratory acidosis & metabolic acidosis?

Answer 119

pCO2 high & the HCO3 low

Question 120

What acid-base disturbance is shown in respiratory alkalosis & metabolic alkalosis?

Answer 120

pCO2 low & the HCO3 high

Question 121

For a patient with metabolic acidosis, what 3 other things would you like to measure?

Answer 121

1. Lactate 2. Ketones (urine dipstick/blood) 3. Glucose (may be elevated in very ill patients due to stress response/dextrose given as IV fluids)

Question 122

What is the anion gap equal to?

Answer 122

[Na+] – ([Cl-] + [HCO3-])

Question 123

What is the normal anion gap?

Answer 123

8–16 mmol/L

Question 124

What is the anion gap used in?

Answer 124

Differential diagnosis of metabolic acidosis

Question 125

Give 4 examples of disorders causing a raised anion gap (excess production of H+/ inability to excrete it)?

Answer 125

1. Renal failure 2. Diabetic or other ketoacidosis 3. Lactic acidosis 4. Toxins e.g. salicylate, some IEM

Question 126

Give 4 examples of disorders causing a normal anion gap (Excess HCO3- loss)?

Answer 126

1. Renal tubular acidosis 2. Diarrhoea 3. Carbonic anhydrase inhibitors 4. Ureteric diversion

Question 127

What is the serum osmolal gap equal to?

Answer 127

Measured osmolality – calculated osmolality

Question 128

What is the calculated osmolality equal to?

Answer 128

2X (Na+ + K+) + urea + glucose (all in mmol/L)

Question 129

What is the normal osmolal gap?

Answer 129

<10mOsm/kg

Question 130

What can also influence the osmolal gap?

Answer 130

Ethanol

Question 131

What does non-invasive ventilation in COPD provide?

Answer 131

Positive pressure to the airways to support breathing

Question 132

When would you consider non-invasive ventilation in COPD?

Answer 132

Respiratory acidosis (pH < 7.35, H+ > 45) present or if acidosis persists despite maximal medical therapy

Question 133

What 5 clinical features of COPD does non-invasive ventilation reduce?

Answer 133

1. Respiratory rate 2. Improves dyspnoea & gas exchange 3. Mortality 4. Need for ventilation in ITU 5. Length of hospital stay

Question 134

What is cor pulmonate a clinical syndrome of?

Answer 134

1. Right heart failure secondary to lung disease | 2. Salt & water retention leading to peripheral oedema

Question 135

What are the 4 signs of cor pulmonale?

Answer 135

1. Peripheral oedema 2. Raised jugular venous pressure 3. A systolic parasternal heave 4. Loud pulmonary second heart sound

Question 136

What 2 things may develop in cor pulmonale?

Answer 136

1. Pulmonary hypertension | 2. Right ventricular hypertrophy may develop

Question 137

What is the treatment for cor pulmonale?

Answer 137

Diuretics to control peripheral oedema

Question 138

What 2 things can severe COPD lead to?

Answer 138

1. Chronic hypercapnic respiratory failure with serum biochemical compensation 2. Cor pulmonale

Question 139

Why is the lung vulnerable to allergy (pathology)?

Answer 139

Because its anatomically weak & has the same entry & exit portal

Question 140

What are the 2 solutions to the unfortunate design of the lungs?

Answer 140

1. Speed/flow airway calibre | 2. Surface area

Question 141

What is the definition of an allergy?

Answer 141

Immune system mediated intolerance

Question 142

What are the 4 things that you need for an allergy?

Answer 142

1. Trigger 2. Recognition- specific response to the trigger 3. Memory- enables you to remember the specific response 4. Immunological response

Question 143

Describe the immediate allergic response?

Answer 143

- Recognition of the trigger by APC & T-cells - IL-4 & IL-33 - Response via IgE, Mast cells

Question 144

Describe the delayed allergic response?

Answer 144

- Recognition of the trigger by APC & T-cell - IL-12 + IFN - Response via reactive T cells

Question 145

What are the 3 types of clinical reactions to allergy?

Answer 145

1. Acute 2. Sudden/Slow 3. Progressive

Question 146

What does chronic allergy lead to?

Answer 146

- Tissue remodelling | - Acute inflammation --> repair

Question 147

Describe allergy in the airways?

Answer 147

Affects airflow: - Increases resistance - Causes wheeze/stridor (turbulence) - Measured by spirometry

Question 148

What 2 tests are not helpful in allergy of the airways?

Answer 148

1. Imaging (CXR) | 2. Gas transfer

Question 149

What are the upper/extra thoracic airways not susceptible to?

Answer 149

Intra-thoracic pressure

Question 150

What is the trachea not susceptible to?

Answer 150

Intra-thoracic pressure

Question 151

Describe extra-thoracic disease clinically?

Answer 151

- Stridor - Flow-volume loops - CXR not helpful - Aspiration to Right middle/lower lobe

Question 152

What is an example of extra-thoracic disease?

Answer 152

Laryngeal oedema (thyroid, scarring, epiglotitis)

Question 153

What is bronchial disease susceptible to?

Answer 153

Intra-thoracic pressure

Question 154

What are the clinical consequences of bronchial disease?

Answer 154

- Medium-Small airways flaccid walls so not supported by cartilage - Expiratory phase narrowing: wheeze - Muco-ciliary clearance impairment (sputum) - Characteristic flow-volume loops

Question 155

What is unhelpful in testing bronchial disease?

Answer 155

CXR – unhelpful (hyperinflation)

Question 156

Describe the spirogram (flow-volume loops) for extrathoracic disease?

Answer 156

- Box like | - Volume has decreased

Question 157

Describe the spirogram (flow-volume loops) for intrathoracic disease?

Answer 157

- Collapsed airway so can't push air through | - Variable

Question 158

Describe the physiological definition of asthma?

Answer 158

Reversible/variable airflow obstruction

Question 159

Describe the pathological definition of asthma?

Answer 159

Airways inflammation/allergy

Question 160

Describe the clinical definition of asthma?

Answer 160

Triggers- cold, exercise, cat, noctrunal/diurnal

Question 161

Describe the morphological appearance of pathological asthma?

Answer 161

- Inflammation - Scabby epithelium - Thickened BM - Thickened smooth muscle - Mast cells in smooth muscle

Question 162

Describe the presentation of physiological asthma?

Answer 162

- Yellow mucous - Repair pathways - Non elastic airways - Increased responsiveness - Increased sensitivity

Question 163

Describe the presentation of clinical asthma?

Answer 163

- Cough/wheeze - Hyper-reactivity - Hyper-sensitivity

Question 164

What are the 3 points to a definition of clinical asthma?

Answer 164

1. Appropriate symptoms with signs- Wheeze, cough, yellow/clear sputum, breathlessness, exercise intolerance 2. Episodic, triggered, variable- paroxysmal 3. Respond to asthma therapies

Question 165

What is characteristic of asthmatic airways?

Answer 165

Airway smooth muscle hypertrophy with infiltration of mast cells

Question 166

Broadly, what 3 things are needed for a diagnosis of asthma?

Answer 166

1. Appropriate clinical story 2. Supportive physiological tests 3. Clinical signs at times of symptoms

Question 167

What are asthmatic "twitchy airways" due to?

Answer 167

Bronchial hypersensitivity (they are more sensitive to histamine)

Question 168

Describe the effect of salbutamol on an asthmatic patient?

Answer 168

Reversible airflow obstruction => 15% improvement in FEV1 after 5mg nebuliser salbutamol

Question 169

Where would you perform a bronchial challenge when testing an asthmatic patient?

Answer 169

Plethysmography Box

Question 170

What 4 cells are involve in airway allergies (asthmatics)?

Answer 170

1. Mast cells 2. Lymphocytes 3. Macrophages 4. Epithelial cells

Question 171

What 6 types of cytokine inflammatory cells are involved in airway allergies (asthmatics)?

Answer 171

1. IL-5 2. TSLP 3. IL-13 4. TNF alpha 5. TGF beta 6. VEGF

Question 172

What does airway allergy drive?

Answer 172

Eosinophillic inflammation

Question 173

Describe inflammatory airway allergy?

Answer 173

- Corticosteroid responsive disease - Routinely identified in airways of asthma - If stimulated will drive an asthma phenotype (viral infections, late allergic reactions) - Multiple candidate genes & non-hierarchical genes associated with asthma are inflammatory

Question 174

What drives allergic airways inflammation/remodelling?

Answer 174

Cytokines

Question 175

In what 4 ways do cytokines in allergic airways cause airway remodelling?

Answer 175

1. Angiogenesis 2. Epithelial cell damage 3. Fibrosis 4. Smooth muscle hypertrophy

Question 176

What are the 4 established specific treatments for asthma?

Answer 176

1. Bronchodilators 2. Anti-leukotriene receptor drugs 3. Corticosteroids 4. Anti-IgE biological therapy

Question 177

What are 4 future specific treatments for asthma?

Answer 177

1. Immunotherapy 2. Biological therapies (TNF, IL-5, IL-13) 3. Thermoplasty 4. Nerve ablation

Question 178

List 9 triggers of extrinsic allergic alveoli's?

Answer 178

1. Bird dander 2. Mushroom worker’s lung 3. Farmer’s lung (fungal spores) 4. Aspergillus lung 5. Cheese workers 6. Wheat weevil 7. Mollusc shell workers 8. Malt worker’s lung 9. Humidifier lung

Question 179

Describe the acute illness which can occur in allergic disease in the lung parenchyma?

Answer 179

- 4-6 hours after exposure - Wheeze, cough, fever, chills, headache, myalgia, malaise, fatigue - May last several days - Serum sickness illness

Question 180

What are 3 factors of immune complex disease?

Answer 180

1. Acute inflammation 2. Neutrophils 3. Consolidation

Question 181

What is the pathological consequence of Peripheral/Parenchymal disease?

Answer 181

Thickening of the septae, filling of the alveolus with fluid

Question 182

List the 2 clinical consequences of Peripheral/Parenchymal disease?

Answer 182

1. Loss of O2- Hypoxaemia (normal CO2) | 2. Air space shadowing on CXR

Question 183

What 2 things occur with chronic exposure to Peripheral/Parenchymal disease?

Answer 183

1. Fibrosis- Interstitial scarring from chronic tissue remodelling/repair pathways 2. Emphysema- Interstitial destruction from neutrophillic enzyme release

Question 184

What law is regarding passive diffusion?

Answer 184

Fick’s law

Question 185

What law is regarding solubility?

Answer 185

Henry's Law

Question 186

How is solubility affected in Peripheral/Parenchymal disease?

Answer 186

- Emphysema= reduced surface area | - Pulmonary fibrosis= increased distance

Question 187

What are the 3 clinical consequences of Peripheral/Parenchymal disease?

Answer 187

- Reduced oxygen transport into the blood stream - Measured by carbon monoxide gas transfer during full PFTs - Airspace shadowing on CXR

Question 188

Describe extrinsic allergic alveolitis and the 2 types of hypersensitivities associated?

Answer 188

- Serum sickness or immune complex disease - Sub acute days to weeks - Type IV T-cell mediated reaction - Type III hypersensitivity reaction (antigen-antibody complexes)

Question 189

What does chronic extrinsic allergic alveolitis lead to?

Answer 189

Fibrosis & emphysema | - Final pathway of all chronic inflammatory conditions

Question 190

What are 3 ways to manage extrinsic allergic alveolitis?

Answer 190

1. Allergy- avoid trigger (occupation) 2. Inflammation- corticosteroids (neutrophils are modestly steroid responsive, cytotoxics) 3. Oxygen supplementation

Question 191

What is the definition of obstructive sleep apnoea?

Answer 191

Recurrent episodes of partial or complete upper (pharyngeal) airway obstruction during sleep, intermittent hypoxia & sleep fragmentation

Question 192

How does obstructive sleep apnoea syndrome manifest clinically?

Answer 192

Excessive daytime sleepiness

Question 193

Describe the mechanism of obstructive sleep apnoea?

Answer 193

Pharyngeal narrowing --> Negative thoracic pressure --> Arousal --> Sleep disruption / Blood pressure surge

Question 194

What are 3 consequences of obstructive sleep apnoea causing sleep disruption?

Answer 194

1. Sleepiness 2. Reduced quality of life 3. Road traffic accidents

Question 195

What are 2 consequences of obstructive sleep apnoea due to blood pressure surge?

Answer 195

1. Heart attacks | 2. Strokes

Question 196

What happens to the airways in obstructive sleep apnoea?

Answer 196

Airway collapses, stopping air from travelling to & from your lungs, disturbing your sleep

Question 197

Describe the epidemiology of obstructive sleep apnoea?

Answer 197

- 25,000,000 snorers in UK (40% population) - 5% of UK adults thought to have undiagnosed OSA - 250,000 men have severe OSA in UK - Men > Premenopausal females - Average age of presentation 40-50 years old - Incidence increasing with obesity epidemic

Question 198

List the 6 symptoms of obstructive sleep apnoea?

Answer 198

1. Snorer 2. Witnessed apnoeas 3. Disruptive sleep- nocturia/choking/dry mouth/ sweating 4. Unrefreshed sleep 5. Daytime somnolence 6. Fatigue/ Low mood/ Poor concentration

Question 199

What are the 7 specialties that patients with obstructive sleep apnoea can be referred on to?

Answer 199

1. GP 2. ENT 3. Pre-operative assessment for elective surgery 4. Post-operative presentation 5. Weight management clinics 6. Diabetes clinic 7. Neurology

Question 200

What is important in a history of obstructive sleep apnoea?

Answer 200

History from partner

Question 201

List 7 things you should assess in a clinical examination of obstructive sleep apnoea?

Answer 201

1. Weight 2. BMI 3. BP 4. Neck circumference (>40cm) 5. Craniofacial appearance (Retrognathia, Micrognathia) 6. Tonsils 7. Nasal patency

Question 202

What are 3 questionnaire that can assess a patients excessive daytime sleepiness?

Answer 202

1. The Epworth Sleepiness Score 2. The STOP-BANG Questionnaire 3. The Berlin Questionnaire

Question 203

What are the 6 investigations in the limited Polysomnography (Limited Sleep Study)?

Answer 203

1. 5 channel home study 2. Oxygen Saturations 3. Heart Rate 4. Flow 5. Thoracic and Abdominal effort 6. Position

Question 204

What are the 9 investigations in a full polysomnography study?

Answer 204

1. EEG- sleep staging 2. Video 3. Audio 4. Thoracic and abdominal bands 5. Position 6. Flow 7. Oxygen Saturations 8. Limb leads 9. Snore

Question 205

What are the 4 advantages of a full polysomnography study?

Answer 205

1. Correct patient 2. Accurate assessment of sleep efficiency 3. Sleep staging via EEG 4. Parasomnic activity- acting out dreams, sleep talking

Question 206

What does TOSCA stand for?

Answer 206

Transcutaneous Oxygen Saturations & Carbon dioxide Assessment (home or inpatient)

Question 207

What is apnoea?

Answer 207

- The cessation, or near cessation, of airflow | - 4% oxygen desaturation, lasting ≥ 10 secs

Question 208

What is hypopnoea?

Answer 208

Reduction of airflow to a degree insufficient to meet the criteria for an apnoea

Question 209

What is respiratory effort related arousals?

Answer 209

Arousals associated with a change in airflow that does not meet the criteria for apnoea or hypopnoea

Question 210

How is Apnoea-Hypopnoea Index (AHI) calculated?

Answer 210

Adding the number of apnoeas & hypopnoeas & dividing by the total sleep time (in hours)

Question 211

What is Oxygen desaturation index (ODI)?

Answer 211

The number of times per hour of sleep that the SpO2 falls ≥ 4% from baseline

Question 212

What Apnoea/Hypopnoea Index (AHI) is diagnostic of obstructive sleep apnoea?

Answer 212

=> 15 OR 5-15 with compatible symptoms

Question 213

Describe the ranges of Apnoea/Hypopnoea Index (AHI) and how they correlate to the severity of obstructive sleep apnoea?

Answer 213

- AHI < 5 Normal - AHI 5-15 Mild - AHI 16-30 Moderate - AHI >30 Severe

Question 214

What is the aim of obstructive sleep apnoea syndrome treatment?

Answer 214

Improve daytime somnolence & QOL

Question 215

What are the 4 means of treatment for obstructive sleep apnoea syndrome?

Answer 215

1. Explain OSAS 2. Weight loss 3. Avoid triggering factors- alcohol 4. Treat underlying conditions- tonsils, hypothyroidism, nasal obstruction

Question 216

What does CPAP stand for?

Answer 216

Continuous positive airways pressure

Question 217

Describe Continuous positive airways pressure (CPAP)?

Answer 217

- Mask over the nose gently directs air into the throat to keep the airway open - Splints airway open - Stops snoring - Stops sleep fragmentation - Improves daytime sleepiness +QOL

Question 218

What is the compliance of Continuous positive airways pressure (CPAP)?

Answer 218

>4hrs for >70% days

Question 219

What are the different types of CPAP?

Answer 219

- Fixed vs Autoset CPAP | - Nasal vs Full Face Mask

Question 220

How would you follow up CPAP treatment?

Answer 220

Annually by physiology once CPAP established

Question 221

Describe the treatment of OSAS (obstructive sleep apnoea syndrome)?

Answer 221

1. Mandibular Advancement Device 2. Mild-moderate OSAS unable to tolerate CPAP 3. Needs good dentition 4. Maxillary-mandibular surgery

Question 222

What 2 cases of OSAS would need Maxillary-mandibular surgery?

Answer 222

1. Problematic patients | 2. Severe retrognathia/micrognathia

Question 223

Decrease sleep position trainers?

Answer 223

- Supine OSA - Vibration when on back - Weeks to change sleeping position - Appropriate in few patients with Supine OSA

Question 224

What 6 consequences can occur due to untreated OSAS?

Answer 224

1. Hypertension 2. Right heart strain 3. Cardiovascular disease 4. Increased risk of CVA 5. Increased accidents at work/poor concentration 6. Increased road traffic accidents

Question 225

How likely is untreated OSAS going to cause road traffic accidents?

Answer 225

4x more likely

Question 226

What is the BTS position statement on driving & OSA/OSAS?

Answer 226

- OSA without daytime somnolence, do not need to stop driving - OSAS (DTS) is likely to impair driving, inform DVLA on diagnosis - OSAS can hold licence if compliant with treatment & reduced DTS - CAT 2 licence require ongoing monitoring by DVLA with regards to treatment complaince

Question 227

What is the standard investigation for Obstructive sleep apnoea?

Answer 227

Limited sleep study

Question 228

What is the main treatment for obstructive sleep apnoea syndrome?

Answer 228

CPAP

Question 229

What is the definition of a pneumothorax?

Answer 229

Air within the pleural cavity

Question 230

Describe the pleural cavity?

Answer 230

- Usually a potential space - Negative intrapleural pressure: opposing forces of chest wall (outwards) & lung (inwards) - Any breach of the pleural space leads to collapse of the elastic lung

Question 231

What are 3 causes of a pneumothorax?

Answer 231

1. Traumatic 2. Iatrogenic 3. Spontaneous

Question 232

Give 2 examples of a traumatic pneumothorax?

Answer 232

1. Stabbing | 2. Fractured rib

Question 233

Give 3 examples of an Iatrogenic pneumothorax?

Answer 233

1. CT guided lung biopsy 2. Transbronchial lung Biopsy 3. Pleural aspiration

Question 234

Give 2 examples of a spontaneous pneumothorax?

Answer 234

1. Primary- young patient, no underlying lung disease | 2. Secondary- underlying lung disease (COPD, cystic fibrosis)

Question 235

Descrive a tension pneumothorax?

Answer 235

- Medical emergency - ‘One way valve’ leads to increased intrapleural pressure - Venous return impaired, cardiac output and blood pressure fall

Question 236

What would happen to a tension pneumothorax if there was no intervention?

Answer 236

Pulseless electrical activity (PEA) cardiac arrest

Question 237

What is the immediate management of a tension pneumothorax?

Answer 237

Insert venflon 2nd intercostal space midclavicular line to relieve pressure

Question 238

What are 4 risk factors for a spontaneous pneumothorax?

Answer 238

1. Smoking 2. Male gender 3. Height 4. Underlying lung disease (secondary)

Question 239

What is the % recurrence rate after 1st episode of a spontaneous pneumothorax?

Answer 239

40-50%

Question 240

Describe the pathophysiology of primary pneumothorax?

Answer 240

- Development of subpleural blebs/ bullae at lung apex - Spontaneous rupture leads to tear in visceral pleura - Air flows from airways to pleural space (pressure gradient) - Elastic lung then collapses

Question 241

What can additionally occur in the pathophysiology of a primary pneumothorax?

Answer 241

Diffuse, microscopic emphysema below the surface of the visceral pleura

Question 242

Describe the pathophysiology of secondary pneumothroax?

Answer 242

- Inherent weakness in lung tissue (eg emphysema) - Increased airway pressure (eg asthma, ventilated patient) - Increased lung elasticity (eg pulmonary fibrosis)

Question 243

Describe the presentation of a secondary pneumothorax?

Answer 243

Patient is generally much more symptomatic (poor underlying lung function)

Question 244

Describe the management of a secondary pneumothorax?

Answer 244

- Management more complex, prognosis less good | - More likely to require intervention

Question 245

List the 3 symptoms of a pneumothorax?

Answer 245

1. Pleuritic chest pain 2. Breathlessness (can be minimal if primary) 3. Respiratory distress (especially if secondary)

Question 246

List the 4 signs of a pneumothorax?

Answer 246

1. Reduced air entry on affected side 2. Hyper-resonance to percussion 3. Reduced vocal resonance 4. Tracheal deviation if tension (+/- circulatory collapse)

Question 247

What are the 3 potential differential diagnosis for a pneumothorax?

Answer 247

1. Pulmonary thromboembolism (PTE) 2. Musculoskeletal pain 3. Pleurisy/ pneumonia

Question 248

What 2 imaging techniques would you use for a pneumothorax?

Answer 248

1. CXR | 2. CT chest

Question 249

Why is the size of pneumothorax less important than symptoms?

Answer 249

- Small pneumothorax very symptomatic if bad COPD | - Can tolerate complete lung collapse very well if healthy

Question 250

What does 2cm rim of air at the axilla equate to?

Answer 250

50% volume

Question 251

What is defined as a small/large pneumothorax?

Answer 251

- <2cm= Small | - >2cm= Large

Question 252

What are the 3 options for pneumothorax management?

Answer 252

1. Observation (serial CXR) if small or not very symptomatic- can be as outpatient 2. Aspiration (small bore catheter 2nd intercostal space midclavicular line- aspirate air with syringe/ 3 way tap) 3. Intercostal drain with underwater seal

Question 253

What 4 interventions are done if a drain fails to work in a pneumothorax?

Answer 253

1. VATS (Video Assisted Thoracic Surgery)- considered if not resolved in 5 days 2. Staple blebs 2. Talc pleurodesis 3. Pleural abrasion/ stripping

Question 254

What does Talc pleurodesis cause?

Answer 254

Causes inflammatory reaction & pleural adhesion, highly effective

Question 255

When would surgical pleurodesis be considered?

Answer 255

If 2nd pneumothorax on same side, 1st contralateral event

Question 256

After a spontaneous pneumothorax has resolved on CXR, how long should the patient wait before flying?

Answer 256

=> 7 days

Question 257

After a spontaneous pneumothorax has resolved on CXR, how long should the patient wait before diving?

Answer 257

Should not dive again (too high a risk of recurring pneumothorax)

Question 258

Describe the prevalence of lung cancer?

Answer 258

- 3rd most common cancer in the UK (2015) - Accounts for 13% of all new cancer cases - In men 2nd commonest after prostate cancer - In women 2nd commonest after breast cancer - >44% of lung cancer occurs in the over 75s, highest in 85-89year olds

Question 259

Where in the UK has the highest incidence rates of lung cancer?

Answer 259

Scotland (3rd higher in Glasgow due to the high smoke prevalence)

Question 260

Describe lung cancer prognosis statistics?

Answer 260

- Long term survival from lung cancer is poor (5%) | - Lung cancer is usually caused by smoking & is therefore in almost 90% of cases a preventable disease

Question 261

Describe lung cancer mortality rates?

Answer 261

- 50% of the deaths occur in over 75 - Overall last decade mortality decreased by 6% (16% decrease in males & 6% increase in females) - More common in people living in deprived areas - Commonest cause of death from malignant disease

Question 262

Describe the survival rates of lung cancer?

Answer 262

- Lowest survival outcome of any cancer - Survival is increasing - ~1/3 of people diagnosed with lung cancer survive at least 1 year after diagnosis - 5% of people diagnosed with lung cancer survive at least 10 years after diagnosis

Question 263

What is 90% of lung cancer due to?

Answer 263

Life style

Question 264

What is the main avoidable risk for lung cancer (89% of cases)?

Answer 264

Smoking- has the strongest link to squamous & small cell

Question 265

Describe the smoking risks of lung cancer?

Answer 265

- <5% are life long non-smokers - 10-20 cig/day : 30x risk - 60 cig/day : 60x risk

Question 266

List 7 other risk factors for lung disease?

Answer 266

1. Environmental tobacco smoke 2. Ionising radiation- radon, uranium 2. Air pollution 3. Asbestos 4. Fibrosing conditions of lung 5. Human papilloma virus 6. Hereditary (polymorphisms in cytochrome p450)

Question 267

List the 6 signs & symptoms of lung cancer?

Answer 267

1. Cough 2. Haemoptysis 3. Shortness of Breath 4. Chest pain 5. Weight loss/Anorexia 6. General malaise

Question 268

What are the 3 main signs & symptoms for a central lung cancer?

Answer 268

1. Haemoptysis 2. Bronchial obstruction- SOB, retention pneumonia 3. Cough

Question 269

What are the 2 signs & symptoms for a peripheral lung cancer?

Answer 269

1. May have few symptoms | 2. Pain if pleura or chest wall involved

Question 270

Where are 6 locations for lung cancer to spread locally?

Answer 270

1. Pleura 2. Hilar lymph nodes 3. Adjacent lung tissue 4. Pericardium 5. Mediastinum 6. Pancoast tumour

Question 271

What can local lung cancer spread to pleura cause?

Answer 271

Haemorrhagic effusion

Question 272

What may lung cancer spread to adjacent lung tissue involve?

Answer 272

Large blood vessel leading to haemoptysis

Question 273

What can pericardial local lung cancer spread cause?

Answer 273

Pericardial effusion with subsequent involvement of pericardium

Question 274

What 3 structures can local mediastinum spread of lung cancer affect?

Answer 274

1. Superior vena caval obstruction 2. Recurrent laryngeal nerve 3. Phrenic nerve

Question 275

What can pancoast tumour spread of lung cancer cause?

Answer 275

- Involvement of brachial plexus giving sensory & motor symptoms - Horner’s syndrome/Oculosympathetic palsy (cervical sympathetic chain)

Question 276

What does local spread of lung cancer causing SVC obstruction lead to?

Answer 276

- Oedema of face & arms - Raised JVP - Dilated veins on chest wall - Plethoric face - Headache worse on stooping

Question 277

What does local spread of lung cancer causing phrenic nerve paralysis lead to?

Answer 277

Diaphragmatic paralysis (the right hemidiaphragm goes up)

Question 278

What does local spread of lung cancer causing recurrent laryngeal nerve paralysis lead to?

Answer 278

Hoarseness of the voice

Question 279

What is Pancoast tumour?

Answer 279

Tumour of the pulmonary apex which can involved brachiocephalic vein, Brachial plexus subclavian etc.

Question 280

List the 3 signs & symptoms of Pancoast tumour?

Answer 280

1. Severe pain in the shoulder or the scapula 2. Pain in the arm & weakness of the hand on the affected side 3. Horner's syndrome

Question 281

Describe Horner's syndrome?

Answer 281

- Due to invasion of cervical sympathetic chain (can be due to Pancoast tumour) - Ptosis - Enophthalmos - Miosis (constriction of pupil) - Anhydrosis

Question 282

List 2 areas that lung cancer can spread to distally?

Answer 282

1. Haematogenous | 2. Lymphatics (cervical lymph nodes)

Question 283

Describe Haematogenous distal spread of lung cancer?

Answer 283

- Common due to invasion of pulmonary veins | - Liver, bone, brain, adrenal

Question 284

Describe Cushing's syndrome?

Answer 284

- ACTH secretion - Adrenal hyperplasia - Raised blood cortisol

Question 285

Describe Syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Answer 285

- ADH secretion - Retention of water - Dilutional hyponatraemia

Question 286

What does the secretion of Parathyroid hormone related peptide (PTHrP) cause?

Answer 286

- Osteoclast activity | - Hypercalcaemia

Question 287

What are the 3 main non-metastatic effects of lung cancer?

Answer 287

1. ACTH secretion 2. ADH secretion 3. Parathyroid hormone related peptide (PTHrP) secretion

Question 288

List 6 other non-metastatic effects of lung cancer?

Answer 288

1. Encephalopathy 2. Cerebellar degeneration 3. Neuropathy 4. Myopathy 5. Eaton Lambert myasthenia-like syndrome 6. Cancer Associated Retinopathy

Question 289

Describe small cell lung cancer?

Answer 289

Usually advanced at diagnosis & responds to chemotherapy

Question 290

Describe non-small cell lung cancer?

Answer 290

May be localised at diagnosis & can be treated by surgery or radiotherapy

Question 291

What is the prevalence of 5 different types of lung cancers by Histology?

Answer 291

1. Adenocarcinoma 40% 2. Squamous cell carcinoma 30% 3. Small cell lung carcinoma 15% 4. Large cell carcinoma 10% 5. Other 3%

Question 292

List 5 other histological types of lung cancers?

Answer 292

1. Mesenchymal Tissues- inflammatory myofibroblastic tumour 2. Salivary gland-type- adenoid cystic carcinoma 3. Ectopic Origin- germ cell tumours 4. Neuroendocrine cells- carcinoid 5. Lymphatic system- lymphoma

Question 293

Why has there been a recent rise in adenocarcinoma & small cell carcinoma with fall in squamous carcinoma?

Answer 293

- Change in smoking demographics (more women now getting lung cancer) - Filter tips, lower tar & nicotine - Deeper inhalation exposes more peripheral airways to carcinogens

Question 294

Describe the site of central lung tumours?

Answer 294

Arise in & around hilus of the lung and are usually squamous or small cell carcinomas

Question 295

What are peripheral lung tumours predominantly?

Answer 295

Adenocarcinomas

Question 296

Describe small cell carcinoma?

Answer 296

- Most aggressive form of lung cancer - Metastasises early & widely - Often initial good response to chemotherapy, but most patients relapse

Question 297

Describe the appearance of small cell carcinoma (4)?

Answer 297

1. Oval to spindle shaped cells 2. Inconspicuous nucleoli 3. Scant cytoplasm 4. Nuclear moulding (more prominent in cytology)

Question 298

What 2 things does small cell carcinomas have in histology?

Answer 298

1. Apoptotic bodies | 2. Nuclear moulding

Question 299

List 3 non-small cell carcinomas?

Answer 299

1. Squamous cell carcinoma 2. Adenocarcinoma 3. Large cell carcinoma

Question 300

Describe squamous cell carcinomas?

Answer 300

- Tend to arise centrally from major bronchi - Often within dysplastic epithelium following squamous metaplasia - Slow growing & metastasise late therefore may be good candidate for surgery

Question 301

What 2 things may happen in squamous cell carcinomas?

Answer 301

1. May undergo cavitation | 2. May block bronchi leading to retention pneumonia or collapse

Question 302

Describe the appearance of squamous cell carcinomas?

Answer 302

- Malignant epithelial tumour showing keratinzation &/or intercellular bridges - In situ squamous cell carcinoma may seen in the adjacent airway mucosa

Question 303

What does squamous tumours produce?

Answer 303

Keratin

Question 304

Describe Adenocarcinoma?

Answer 304

- Common tumour in females - Seen in non-smokers (but also associated with smoking) - 2/3s arise in periphery sometimes in relation to scarring

Question 305

Describe the appearance of an Adenocarcinoma?

Answer 305

- Glandular, solid, papillary or lepidic | - Mucin production

Question 306

Describe large cell carcinoma?

Answer 306

- Usually arises centrally - Undifferentiated malignant epithelial tumour that lacks the cytological features of SCLC & glandular or squamous differentiation

Question 307

How do you diagnose large cell carcinoma?

Answer 307

Diagnosis of exclusion

Question 308

Describe a carcinoid tumour?

Answer 308

- Tumour of neuroendocrine cells - Central or peripheral - Classified as Typical or Atypical

Question 309

Describe the prognosis of carcinoid tumours?

Answer 309

Can metastasize but MUCH better prognosis than other conventional lung cancers (5YS for typical 85-90%; Atypical 5YS 50-75%)

Question 310

List 3 molecular targets identified for lung cancer?

Answer 310

1. Epidermal Growth Factor Receptor (EGFR) 2. Echinoderm Microtubule-Associated Protein like 4-Anplastic lymphoma kinase fusion gene 3. Immunotherapy- PDL1

Question 311

Describe the function of Epidermal Growth Factor Receptor (EGFR)?

Answer 311

- Extracellular component is responsible for ligand binding - Intracellular component consists of the tyrosine kinase which is responsible for signal transduction & activates several growth pathways

Question 312

What can mutations of EGFR cause?

Answer 312

It to become constitutionally active.

Question 313

How would you test for mutations in EGFR?

Answer 313

- Performed on biopsy or cytology specimens | - PCR or Sequencing used to look for mutations in EGFR

Question 314

What are deletions in EGFR Exon 19 commonly associated with?

Answer 314

Good response to EGFR inhibitors

Question 315

What does ALK & EML4 fusion lead to?

Answer 315

Constitutive activation of a chimeric tyrosine kinase leading to increased cell proliferation

Question 316

What drug inhibits ALK & EML4 fusion & hence inhibits cell proliferation?

Answer 316

Crizotinib

Question 317

What are 2 ways to test for ALK fusion?

Answer 317

1. FISH | 2. Immunohistochemistry for protein product

Question 318

Describe PDL1 in lung cancer?

Answer 318

PD-L1 binds to PD-1 & inhibits T cell killing of tumour cell

Question 319

What can mutated EGFR receptors (~13% in glasgow) respond to?

Answer 319

Tyrosine kinase inhibitors (ROS-1)

Question 320

What do ~3-7% of NSCLC patients have?

Answer 320

EML4-ALK gene fusions present in their tumours, which may respond to ALK-inhibitors

Question 321

What is over-expressed in 30-40% of tumours?

Answer 321

PD-L1 & may be treated with PD-L1 inhibitors

Question 322

List the 9 common sites of secondary cancers which spread to the lung?

Answer 322

1. Breast 2. Colorectal 3. Kidney 4. Head and neck 5. Testicular 6. Bone (osteosarcoma) 7. Sarcomas 8. Melanoma 9. Thyroid

Question 323

List the 6 signs & symptoms of secondary cancer to the lungs?

Answer 323

1. Cough 2. Shortness of breath 3. Frequent chest infections 4. Haemoptysis 5. Pain 6. Weight loss

Question 324

What is mesothelioma?

Answer 324

Primary pleural tumour (also occurs in peritoneum, pericardium & tunica vaginalis testis)

Question 325

Describe Mesothelioma?

Answer 325

- Almost always due to asbestos exposure - Very long lag period - Either an epithelial or sarcomatoid appearance or a mixture of both (biphasic)

Question 326

Describe a mesothelioma on CT scan?

Answer 326

- Encases the lung | - Mass in the pleura

Question 327

What is often found in the sputum of someone with a mesothelioma?

Answer 327

Asbestos body

Question 328

What is sarcoidosis?

Answer 328

Multisystem inflammatory disease of unknown etiology that predominantly affects the lungs & intrathoracic lymph nodes

Question 329

Describe the presentation of sarcoidosis?

Answer 329

- ~5% of cases are asymptomatic & incidentally detected by CXR - Presentation depends on the extent & severity of the organ involved

Question 330

List the 5 systemic symptoms that occur in 45% of sarcoidosis cases?

Answer 330

1. Fever 2. Anorexia 3. Fatigue 4. Night sweats 5. Weight loss

Question 331

What symptoms occur in 50% of sarcoidosis patients?

Answer 331

Pulmonary, dyspnea on exertion, cough, chest pain & hemoptysis (rare)

Question 332

List the 5 clinical signs of sarcoidosis?

Answer 332

1. Pulmonary findings 2. Dermatological manifestations 3. Ocular manifestations 4. Cardiac manifestations 5. Neurologic manifestations (rare)

Question 333

How is sarcoidosis diagnosed?

Answer 333

- You can see on a chest X-ray & what organs are affected - Bronchoscopy & perhaps take a tissue biopsy

Question 334

List the 4 lung signs of sarcoidosis?

Answer 334

1. Dyspnea 2. Cough 3. Vague chest discomfort 4. Wheezing

Question 335

Describe the 4 stages of chest radiographs in patients with sarcoidosis?

Answer 335

- Stage 1: bilateral hilar lymphadenopathy without infiltration - Stage 2: bilateral hilar lymphadenopathy with infiltration - Stage 3: infiltration alone - Stage 4: fibrotic bands, bullae, hilar retraction, bronchiectasis & diaphragmatic tenting

Question 336

What do/don't the stages of lung sarcoidosis represent?

Answer 336

- Represent radiographic patterns | - Don't indicate disease chronicity or correlate with changes in pulmonary function

Question 337

Describe the lung histology of sarcoidosis?

Answer 337

- Schaumann body - Granuloma (collection of activated macrophages) - Giant cell of lots of nuclei - Non-necrotising granulomas inflammation (giant cells) - Asteroid bodies (not diagnostic of sarcoidosis but its consistent with it)

Question 338

What is sarcoidosis characterised by?

Answer 338

Non-necrotising Granulomatous Inflammation

Question 339

Sarcoidosis is a diagnosis of _____?

Answer 339

Exclusion

Question 340

Describe the 2 issues with pulmonary fibrosis?

Answer 340

1. A lot of causes for Pulmonary Fibrosis 2. It is a difficult diagnosis to make in some cases & the whole picture has to add up: Radiology, Pathology & Clinical

Question 341

What is Idiopathic pulmonary fibrosis (IPF)?

Answer 341

Clinical manifestation or equivalent of the pathological diagnosis usual interstitial pneumonia (UIP)

Question 342

Describe the prognosis of usual interstitial pneumonia (UIP)?

Answer 342

High mortality, 50% are dead after 2 years

Question 343

What is pulmonary Fibrosis?

Answer 343

Fibrosis which is not caused by other causes & affects the respiratory apparatus of the lungs

Question 344

Describe the epidemiology of Idiopathic Pulmonary Fibrosis (IPF)?

Answer 344

- Age > 50 | - M:F - 2:1

Question 345

Describe the signs & symptoms of Pulmonary Fibrosis?

Answer 345

- Progressive breathlessness (worse with exercise) - Bibasilar crackles - Hacking dry cough - Fatigue & weakness - Appetite & weight loss - Clubbing - PERIPHERAL Interstitial pattern

Question 346

What is the main feature of a post-mortem Idiopathic Pulmonary Fibrosis (IPF) lung?

Answer 346

Subpleural honeycombing

Question 347

List the 6 potential causes of pulmonary fibrosis?

Answer 347

1. Occupational & Environmental- Asbestosis, Hypersensitivity Pneumonitis 2. Drug Induced-Nitrofurantoin, Methotrexate, Cocaine 3. Connective Tissue Diseases- Lupus, RA 4. Primary Diseases- Sarcoidosis 5. Idiopathic (25%)- IPF, NSIP 6. Genetics

Question 348

How do you diagnose pulmonary fibrosis?

Answer 348

High-resolution computed tomography (HRCT) & if this shows no signs then do a biopsy (at least 3)

Question 349

What does VATS stand for?

Answer 349

Video-Assisted Thoracoscopic Surgery

Question 350

Describe the histological appearance of pulmonary fibrosis?

Answer 350

- Fibroblastic focus is not diagnostic but a feature of UIP - Smooth muscle hyperplasia can occur in IUP which is a sign of long term scarring - Temporal heterogenity, means there are different evolutions of scar formation - Free radicals in the alveoli

Question 351

Describe how lung fibrosis is formed?

Answer 351

Repetitive alveolar epithelial injury --> Altered alveolar microenvironment --> Dysregulated repair, loss of epithelial cells, accumulation of mesenchymal cells --> Fibrosis

Question 352

What is Extrinsic Allergic Alveolitis (EAA)/ Henoch Schönlein Purpura (HSP)?

Answer 352

- Immunologically mediated inflammatory reaction in the alveoli & in the bronchioles - It is NOT atopy, It is a T-cell mediated response

Question 353

List the 4 causes of Extrinsic Allergic Alveolitis (EAA)/ Henoch Schönlein Purpura (HSP)?

Answer 353

1. Organic dusts (<5µm) 2. Moulds 3. Foreign proteins (animals) 4. Some chemicals (lots of others) - Often heavy, repeated exposure, most often at the work place

Question 354

List 10 examples of Extrinsic Allergic Alveolitis (EAA)?

Answer 354

1. Farmer's lung 2. Saw mill worker's lung 3. Bird fancier's lung 4. Mushroom workers lung 5. Malt workers lung 6. Humidifier lung 7. Cheese washer's lung 8. Suberosis 9. Diisocyanate lung 10. Hard metal worker's lung

Question 355

List the 5 symptoms of Extrinsic Allergic Alveolitis (EAA)/ Henoch Schönlein Purpura (HSP)?

Answer 355

1. Flu-like illness 2. Cough 3. High fever, chills 4. Dyspnea, chest tightness 5. Malaise 6. Myalgia

Question 356

When do symptoms occur in Extrinsic Allergic Alveolitis (EAA)/ Henoch Schönlein Purpura (HSP)?

Answer 356

4-8 hours after exposure

Question 357

List the 5 symptoms in CHRONIC Extrinsic Allergic Alveolitis (EAA)/ Henoch Schönlein Purpura (HSP)?

Answer 357

1. Dyspnea in strain 2. Sputum production 3. Fatigue 4. Anorexia 5. Weight loss

Question 358

Describe the chest X ray appearance of acute Henoch Schönlein Purpura (HSP)?

Answer 358

- Numerous poorly defined small ( < 5 mm) opacities in both lungs - Sometimes sparing of apices & bases - Airspace disease: usually seen as ground glass opacities - Fine reticulation may also occur zonal distribution

Question 359

Describe the pathological appearance of Extrinsic Allergic Alveolitis (EAA)/ Henoch Schönlein Purpura (HSP)?

Answer 359

- Bronchiolocentric pattern - Non-necrotising granulation - Foamy macrophages in alveolar spaces - Chronic interstitial inflammation (alveoli) - Organising pneumonia

Question 360

Sarcoidosis the inflammation is in the ___________, in the hypersensitivity pneumonitis it’s in the __________?

Answer 360

1. Interstitium | 2. Airspaces

Question 361

What 7 things do you give in life threatening acute exacerbation of asthma?

Answer 361

1. High flow oxygen 2. Nebulised bronchodilators (500mg salbutamol, 500mcg ipatropium bromide) 3. Oral prednisolone 40mg 4. Oral doxycycline 200mg 5. IV magnesium 2g 6. Discussion with ITU

Question 362

What would you consider giving for life threatening acute exacerbation of asthma?

Answer 362

IV aminophylline infusion

Question 363

What is the normal dose of amoxicillin?

Answer 363

500mg orally 8 hourly/ 1g intravenously 8 hourly

Question 364

What is the mechanism of action of amoxicillin?

Answer 364

Inhibits bacterial cell wall synthesis

Question 365

What are 2 important Pharmacokinetics / Pharmacodynamics of amoxicillin?

Answer 365

1. Beta-lactamase production is the most common mechanism of resistance 2. Predominantly renally excreted

Question 366

What is the normal dose of Clarithromycin?

Answer 366

500 mg orally 12 hourly

Question 367

What is the mechanism of action of Clarithromycin?

Answer 367

Bacteriostatic drug inhibiting protein synthesis

Question 368

What are 3 side effects of Clarithromycin's mechanism of action?

Answer 368

1. Rapidly absorbed orally- can cause phlebitis IV so avoid 2. Hepatic metabolism- caution in liver failure & reduce dose in significant renal impairment 3. Inhibits CYP450 (theophylline warfarin, carbamazepine, digoxin, phenytoin, simvastatin (myopathy))

Question 369

What should you be cautious about when prescribing Clarithromycin?

Answer 369

QT prolongation

Question 370

What is the normal dose of Doxycycline?

Answer 370

200mg then 100mg daily (oral)

Question 371

Describe Doxycycline?

Answer 371

Tetracycline, broad range of activity, long half-life

Question 372

What is the mechanism of action of Doxycycline?

Answer 372

- Bacteriostatic drug, inhibits addition of amino acids to growing peptide - Well absorbed orally

Question 373

When should you be cautious in prescribing Doxycycline?

Answer 373

- Patients with hepatic impairment | - Chelates calcium so avoid in young children & pregnancy

Question 374

What is the normal dose for co-amoxiclav?

Answer 374

625mg orally 8 hourly/ 1.2g intravenously 8 hourly

Question 375

Describe the mechanism of action of clavulanic acid (in co-amoxiclav)?

Answer 375

Irreversible inhibitor of β-lactamases – prevents cleavage of amoxicillin

Question 376

When should you be caution in prescribing co-amoxiclav?

Answer 376

Predominantly renally excreted therefore reduce dose in severe renal impairment

Question 377

Describe the mechanism of action of corticosteroids?

Answer 377

Bind to activated glucocorticoid receptors to suppress multiple pro-inflammatory genes that are activated in asthmatic airways by reversing histone acetylation

Question 378

What are the 3 indications for corticosteroid prescription?

Answer 378

1. Asthma 2. COPD with recurrent exacerbations 3. Exacerbations of asthma/COPD

Question 379

List the 13 side effects of corticosteroids (there are many others)?

Answer 379

1. Diabetes 2. Osteoporosis 3. Hypertension 4. Muscle wasting 5. Peptic ulceration 6. Cataracts 7. Cushing’s syndrome 8. Adrenal suppression 9. Acute pancreatitis 10. Hyperlipidaemia 11. Increased appetite 12. Salt & water retention 13. Immune suppression

Question 380

Describe the mechanism of action of Bronchodilators: 𝛃2 agonist?

Answer 380

- Higher specificity for pulmonary (𝛃2) receptors vs. cardiac (𝛃1) receptors - Stimulate adenyl cyclase to increase intracellular cAMP --> relaxation of bronchial smooth muscle

Question 381

What are 2 indications for Bronchodilators: 𝛃2 agonist?

Answer 381

1. Treatment of asthma | 2. Treatment of COPD

Question 382

List 9 side effects of Bronchodilators: 𝛃2 agonist?

Answer 382

1. Tremor 2. Hypokalaemia 3. Hyperglycaemia 4. Hypomagnesaemia 5. Flushing 6. Tachycardia 7. Arrhythmias 8. Headache 9. Muscle cramps

Question 383

What are 2 examples of short acting Bronchodilators: 𝛃2 agonist?

Answer 383

Salbutamol & Terbutaline (elimination half-life ~3 – 5 hours)

Question 384

What are 4 examples of long acting Bronchodilators: 𝛃2 agonist?

Answer 384

1. Salmeterol 2. Formoterol 3. Vilanterol 4. Indacaterol

Question 385

List 4 routes of administration for salbutamol?

Answer 385

1. Inhaled (preferred) 2. Nebulised (if severe) 3. Oral 4. IV

Question 386

What is the mechanism of action of Bronchodilators: Anti-muscarinics?

Answer 386

Inhibition of cholinergic M1 & M3 receptors in lung --> reduction in cGMP & inhibition of parasympathetic-mediated bronchoconstriction

Question 387

List the 5 side effects of bronchodilators: Anti-muscarinics?

Answer 387

1. Blurred vision 2. Dry mouth 3. Urinary retention 4. Nausea 5. Constipation

Question 388

What may nebulised ipatropium precipitate?

Answer 388

Acute angle closure glaucoma – use a mouthpiece not a mask

Question 389

Give an example of a short acting bronchodilators: Anti-muscarinics?

Answer 389

Ipatropium bromide

Question 390

Give 3 examples of long acting bronchodilators: Anti-muscarinics?

Answer 390

1. Tiotropium 2. Glycopyrronium 3. Umeclidinium

Question 391

How are bronchodilators: Anti-muscarinics excreted?

Answer 391

Renally

Question 392

What is the mechanism of action for Bronchodilators: Methylxanthines?

Answer 392

- Non-selective inhibition of phosphodiesterase --> increased intracellular cAMP --> bronchial smooth muscle relaxation - Immunomodulatory action: improved mucociliary clearance & anti-inflammatory effect

Question 393

Give 2 examples of Bronchodilators: Methylxanthines?

Answer 393

1. Aminophylline | 2. Theophylline

Question 394

What is an indication for Bronchodilators: Methylxanthines?

Answer 394

Adjunct to inhaled therapy in asthma/intravenous infusion in severe exacerbations of asthma

Question 395

List 6 side effects of Bronchodilators: Methylxanthines?

Answer 395

1. GI upset 2. Palpitations 3. Tachycardia/arrhythmias 4. Headache 5. Insomnia 6. Hypokalaemia

Question 396

What are important Pharmacokinetics / Pharmacodynamics for Bronchodilators: Methylxanthines?

Answer 396

Time to steady state: 2- 3 days, plasma theophylline levels at 5 days/3 days after dose adjustment

Question 397

What is the problem with Bronchodilators: Methylxanthines?

Answer 397

Narrow therapeutic window: 10 – 20mg/L so drug monitoring: 4 – 6 hours post-dose

Question 398

What can Bronchodilators: Methylxanthines toxicity do?

Answer 398

1. Severe vomiting 2. Hypokalaemia/hypocalcaemia 3. Seizures 4. Arrhythmias 5. Hypotension 6. Weight-based dosing

Question 399

Where is Bronchodilators: Methylxanthines metabolised?

Answer 399

Liver- caution in liver disease & with concomitant use of enzyme inducers (rifampicin) and inhibitors (clarithromycin, ciprofloxacin)

Question 400

What increases theophylline (Bronchodilators: Methylxanthines) clearance?

Answer 400

Smoking

Question 401

Give 3 examples of LABA/LAMA combination inhalers?

Answer 401

1. Anoro ® Ellipta (Umeclidinium/Vilanterol) 2. Ultibro ® Breezhaler (Glycopyrronium/Indacaterol) 3. Duaklir ® Genuair (Aclidinium/Formoterol)

Question 402

Give 4 examples of LABA/ICS combination inhalers?

Answer 402

1. Relvar ® Ellipta (Fluticasone/Vilanterol) 2. Seretide ® Accuhaler/Evohaler (Fluticasone/Salmeterol) 3. Symbicort ® Turbohaler (Budesonide/Formoterol) 4. Fostair MDI (Beclometasone/Formoterol)

Question 403

Give 2 examples of Leukotriene receptor antagonists used in asthma?

Answer 403

1. Montelukast | 2. Zafirlukast

Question 404

What is the mechanism of action of Leukotriene receptor antagonists?

Answer 404

Bind with high affinity to cysteinyl leukotriene receptor (CysLT1) inhibiting action of LTD4 in smooth muscle cells of the airway and airway macrophages --> reduced airway oedema & smooth muscle contraction

Question 405

What are Leukotriene receptor antagonists useful for?

Answer 405

Prophylaxis of exercise-induced asthma, allergic rhinitis

Question 406

Leukotriene receptor antagonists have a ___ half-life?

Answer 406

Short

Question 407

Describe Omalizumab (Leukotriene receptor antagonists)?

Answer 407

- Monoclonal anti-IgE antibody - Severe persistent allergic asthma - Subcutaneous injection every 4 weeks - Dose based on IgE & weight - Risk of severe hypersensitivity reaction

Question 408

Describe Mepolizumab (Leukotriene receptor antagonists)?

Answer 408

- Anti-IL5 monoclonal antibody - Reduces circulating eosinophils - Severe refractory eosinophilic asthma - Subcutaneous injection every 4 weeks - Headaches commonly reported

Question 409

Describe the GOLD COPD Guideline?

Answer 409

Spirometrically confirmed diagnosis (post-bronchodilator FEV1/FVC < 0.7) --> Assessment of airflow limitation --> Exacerbation history --> Assessment of symptoms/risk of exacerbations (A,B,C,D)

Question 410

What is Roflumilast drug?

Answer 410

Selective inhibitor of phosphodiesterase-4

Question 411

What is the mechanism of action of Roflumilast?

Answer 411

Inhibits hydrolysis of cAMP in inflammatory cells --> increased intracellular cAMP --> reduced release of pro-inflammatory mediators & cytokines

Question 412

How is Roflumilast metabolised?

Answer 412

By cytochrome P450

Question 413

What is the indication for Roflumilast?

Answer 413

Reduction in exacerbations of COPD

Question 414

What is the mechanism of action of Azithromycin?

Answer 414

Macrolide antibiotic with immunomodulatory & anti-inflammatory effects- inhibition of pro-inflammatory AP-1, NFκB & mucin release

Question 415

What is the indication for Azithromycin?

Answer 415

Reduction in exacerbations of COPD

Question 416

What is the mechanism of action of Carbocisteine?

Answer 416

Increases concentrations of sialomucins & reduces concentrations of fucomucins resulting in reduced sputum viscosity

Question 417

What is the indication for Carbocisteine?

Answer 417

Reduction in exaerbations of COPD

Question 418

What is Dermatophytes?

Answer 418

Fungi that cause common infections of skin, nails & hair

Question 419

Describe Dermatophytes infections?

Answer 419

- Do not colonise ‘live’ tissues, instead keratinised areas such as nails & outer skin - Healthy & immunocompromised infected

Question 420

What are 3 virulence factors for Dermatophytes?

Answer 420

Keratinases, elastase & other proteinases

Question 421

What are Dermatophytes infections also known as?

Answer 421

- Ringworm | - Tinea

Question 422

When would you treat dermatophytes infection with oral medication?

Answer 422

- Severe infections, nail infections - Topical medication has not worked - Adults only

Question 423

Give 4 examples of active ingredients for treating dermatophytes infection?

Answer 423

1. Terbinafine (Lamisil®) 2. Itraconazole 3. Ketoconazole 4. Miconazole

Question 424

Give 3 examples of systemic fungal infections & their causes?

Answer 424

1. Fungal meningitis- Cryptococcus neoformans 2. Aspergillosis of the lungs- Aspergillus fumigatus 3. Pneumocystis pneumonia- Pneumocystis jiroveci

Question 425

Who get systemic fungal infections?

Answer 425

Only immunocompromised

Question 426

Describe Cryptococcus neoformans?

Answer 426

- Inhaled opportunistic pathogen - Encapsulated yeast - Contracted from environment, e.g. pigeon droppings

Question 427

What is often a secondary infection with HIV?

Answer 427

Crytococcosis of lungs, & meningitis

Question 428

What is the treatment of Cryptococcus neoformans infection?

Answer 428

- 2 weeks of i.v. Amphotericin B for meningitis | - Fluconazole or flucytosine (non-CNS)

Question 429

What are 3 types of aspergillum fumigatus infections?

Answer 429

1. Allergic bronchopulmonary aspergillosis (ABPA) 2. Invasive pulmonary aspergillosis (IPA) 3. Aspergilloma

Question 430

Describe Allergic bronchopulmonary aspergillosis (ABPA)?

Answer 430

- Allergic reaction to the fungal infection - Association with cystic fibrosis, asthma - Prednisone (anti-allergic agent)

Question 431

Describe Invasive pulmonary aspergillosis (IPA)?

Answer 431

- Becomes systemic & spreads throughout the body - Common in immunocompromised - Treatment: voriconazole; Amphotericin B

Question 432

Describe Aspergilloma?

Answer 432

- Fungal ball that develops in an area of past lung disease or lung scarring - e.g. tuberculosis or lung abscess - No treatment unless bleeding occurs: surgery

Question 433

What is Pneumocystis jiroveci?

Answer 433

Common environmental fungus

Question 434

What can Pneumocystis jiroveci cause?

Answer 434

Pneumonia (fever, cough, shortness of breath, rapid breathing)

Question 435

How do you treat Pneumocystis jiroveci?

Answer 435

Trimethoprim-sulfamethoxazole

Question 436

What is the largest class of antifungal agents?

Answer 436

Imidazole, triazole, & thiazole antifungals

Question 437

Give 8 examples of Imidazole, triazole, & thiazole antifungals?

Answer 437

1. Miconazole (Micatin® or Daktarin®) 2. Ketoconazole (Nizoral, Fungoral and Sebizole®) 3. Clotrimazole (Lotrimin, Lotrimin AF and Canesten) 4. Econazole 5. Isoconazole 6. Fluconazole 7. Itraconazole 8. Abafungin

Question 438

What are azoles?

Answer 438

Inhibitors of 14-methylsterol α-demethylase which produces ergosterol

Question 439

Describe ergosterol?

Answer 439

- Essential component of the fungal plasma membrane - Does not occur in animal or plants cells - Equivalent of cholesterol in yeast, fungi

Question 440

What does Terbinafine inhibit?

Answer 440

Squalene 2,3-epoxidase

Question 441

What does Azoles inhibit?

Answer 441

14-methylsterol α-demethylase

Question 442

What does Ketoconazole inhibit?

Answer 442

1 enzyme in ergosterol synthesis

Question 443

What is the drawback of Ketoconazole?

Answer 443

Cross- resistance

Question 444

Why are sterols, such as cholesterol, so important?

Answer 444

They insert themselves into the lipid bilayer & are essential for its proper functioning & viscosity

Question 445

What does Amphotericin B exploit?

Answer 445

- Ergosterol / cholesterol difference | - Presence of ergosterol (hydrophobic side interacts with ergosterol)

Question 446

What does binding of Amphotericin B to ergosterol cause?

Answer 446

Intercalation of cell membrane (pore in fungal membranes) & leakage of intracellular cations & eventual cell death

Question 447

What is ambisome?

Answer 447

Liposome formulation with amphotericin B molecules

Question 448

What are the 2 benefits of ambisome?

Answer 448

1. Improved delivery | 2. Reduced Toxicity

Question 449

What does the mediastinum consist of?

Answer 449

Blood vessels, trachea, oseophagus, T duct & phrenic nerves, Thymus (8mm lobe young adults, 5mm > 50yrs)

Question 450

What are the 3 lung fissures?

Answer 450

1. Major 2. Minor 3. Azygous

Question 451

What lung hila is higher up?

Answer 451

Left higher than right

Question 452

What is the size of lung paraspinal lines?

Answer 452

<10 mm

Question 453

What is mediastinal drift associated with?

Answer 453

Collapse/Consolidation

Question 454

What is the mediastinum best visualised on?

Answer 454

CT

Question 455

What is the main rule for assessing the mediastinum on imaging?

Answer 455

2 vessels in front (veins) & 3 arteries behind

Question 456

Describe the aorta on a chest CT?

Answer 456

- Ascending aorta in front | - Descending aorta behind

Question 457

What are small dots on a chest CT usually?

Answer 457

Lymph nodes (normal)

Question 458

How big should lymph nodes be?

Answer 458

<1cmn

Question 459

What 4 disease cause bilateral hilar adenopathy?

Answer 459

1. Sarcoidosis 2. Lymphoma 3. TB 4. Malignancy

Question 460

Describe a mediastinal lymphoma on CXR?

Answer 460

Wide ascending aorta

Question 461

Does lobar collapse normally cause mediastinal shift?

Answer 461

NO

Question 462

What are the 4 CXR signs of right UL collapse?

Answer 462

1. Opacification right upper zone 2. Displacement of the horizontal fissure superiorly 3. Bulging of fissure medially 4. Trachea displaced to right

Question 463

What is Golden’s reverse's sign?

Answer 463

Bulging of fissure medially

Question 464

What should you always suspect when there is a collapsed lung/lobe?

Answer 464

Tumour but other causes are possible

Question 465

What 5 investigations would you do for a suspected collapsed lung/lobe?

Answer 465

1. History 2. Examination 3. Bloods 4. CT 5. Bronchoscopy

Question 466

What are 4 CXR signs of left UL collapse?

Answer 466

1. Opacification left upper zone 2. Displacement of the oblique fissure superiorly 3. Bulging of fissure medially 4. Trachea displaced to left

Question 467

What may be seen in a CXR of left UL collapse?

Answer 467

Veil like opacification of left hemithorax & aereated left apex due to expanded left lower lobe +/- elevated left hemidiaphram

Question 468

What are 4 CXR signs of left LL collapse?

Answer 468

1. Wedge triangular opacification behind the left heart border “sail boat sign” 2. Displacement of the left hilum inferiorly 3. Obliteration of the left hemidiaphragm 4. Hyperlucent remaining left lung

Question 469

What are 4 causes of a hyperlucent lung?

Answer 469

1. Ring shadows- bullae 2. Technical causes- rotation 3. Chest wall/pleural abnormalities 4. Vascular e.g. PTE

Question 470

What can appear like a pneumothorax on CXR?

Answer 470

Skin fold

Question 471

What is the main cause of a hyper lucent lung with mediastinal shift?

Answer 471

Pneumothorax (air in pleural space)

Question 472

What are 4 types of pneumothorax?

Answer 472

1. Simple 2. Hydro 3. Haemo 4. Pyo

Question 473

What is a pneumothorax usually due to?

Answer 473

Spontaneous rupture of pleural bleb

Question 474

What should you identify on a CXR of pneumothorax?

Answer 474

Pleural line (visceral)

Question 475

What are 4 difficulties of diagnosing pneumothorax on a CXR?

Answer 475

1. Bullae 2. Clothing 3. Tubes 4. Skin folds

Question 476

What may be helpful when diagnosing a pneumothorax?

Answer 476

Expiratory film

Question 477

Describe a pneumothorax on a supine film?

Answer 477

- Deep costophrenic angle - Increased clarity of mediastinual border - Depression of diaphragm - Visualisation of undersurface of the heart

Question 478

List the 9 causes of a pneumothorax?

Answer 478

1. Trauma- stab, iatrogenic, rib fracture 2. Spontaneous 3. Ventilation 4. Pulmonary disease- fibroses 5. Asthma 6. Infections- TB, sepsis, septic infarct 7. Malignancy- metasatic sarcoma 8. Pneumomediastium- ruptured oesophagus, tracheostomy 9. Obscure- Endometriosis

Question 479

List the 6 radiological signs on the CXR for a pneumothorax?

Answer 479

1. Depression of the left hemidiaphragm 2. Tracheal displacement 3. Hyperlucency of the left hemithorax 4. Small left basal pleural effusion 5. Displacement of the heart to the right 6. Pleural line or completely collapsed lung

Question 480

List 5 complications of a pneumothorax?

Answer 480

1. Haemothorax 2. Tension 3. Adhesions 4. Delayed expansion adhesions, airways obstruction 5. Re expansion oedema

Question 481

What is a pleural effusion?

Answer 481

- Fluid in the pleural space | - Normally fluid generated by parietal, absorbed by visceral

Question 482

What can lateral decubitas film detect in a pleural effusion?

Answer 482

50-10ml fluid

Question 483

What are the 5 types of fluid causing a pleural effusion?

Answer 483

1. Transudate 2. Exudate 3. Blood- Haemothorax 4. Chyle- Chylothorax 5. Mixed

Question 484

What is the most common cause of a pleural effusion?

Answer 484

Cardiac failure

Question 485

List 9 causes of pleural effusions?

Answer 485

1. Hypoproteinaemia- cirrhosis 2. Cardiovascular- CCF, constrictive pericarditis 3. Neoplasm 4. Infection 5. Trauma 6. Thromboembolism 7. Inhalation- asbestos 8. Collagen vascular disease- SLE, RA 9. Subdiaphragmatic disease- pancreatitis, subphrenic abscess

Question 486

What are the 5 most likely causes of a massive pleural effusion?

Answer 486

1. Malignant disease 2. Heart failure 3. Cirrhosis 4. TB 5. Empyema 6. Trauma

Question 487

What are 8 causes of an opacification of the hemithorax (half of the thorax)?

Answer 487

1. Pleural effusion 2. Consolidation 3. Collapse 4. Massive tumour 5. Fibrothorax 6. Combination of above 7. Pneumonectomy 8. Lung agenesis

Question 488

What are 5 CXR signs for a pleural effusion?

Answer 488

1. Lat decubitas most sensitive- 5mls 2. PA CXR; 200mls + 3. Blunting costo phrenic angle & meniscus sign 4. Supine film; hazy opacification & visualised vascular markings 5. Massive effusion with contralateral shift

Question 489

What can massive effusions cause occasionally?

Answer 489

Diaphragmatic inversion, more common on left

Question 490

What is Subpulmonary effusion?

Answer 490

- Free fluid collects initially under lung | - When >2-300ml becomes generalised

Question 491

Describe the CXR of a Subpulmonary effusion?

Answer 491

- High hemidiaphragm (appears more opaque) | - Lateral peak to contour

Question 492

How is a subpulmonary effusion confirmed?

Answer 492

Lateral decubitus film

Question 493

What are 4 other investigations for a pleural effusion?

Answer 493

1. Move fluid e.g. supine lat decubitas 2. Post aspiration of fluid analysis 3. Post aspiration film 4. CT

Question 494

Where can fluid be loculated in a pleural effusion?

Answer 494

1. Fissures- visceral/parietal | 2. Chest wall- visceral/parietal

Question 495

Describe Fissural pleural effusion fluid?

Answer 495

- Especially heart failure- phantom tumour - PA thin or mass like - Lateral: sharp margins, biconvex with tail along fissure

Question 496

Describe Chest Wall pleural effusion fluid?

Answer 496

PA pleural shadow with one edge sharp & one that fades

Question 497

What moves & what does not in the mediastinum?

Answer 497

Fluid moves, parenchymal pathology does not

Question 498

Describe a Haemothorax?

Answer 498

- Identical to all pleural collections - Trauma commonest - Also seen in leaking aortic aneurysm, pneumothorax or bleeding tendency

Question 499

Describe the appearance of a Chylothorax?

Answer 499

- Right sided with low thoracic pathology | - Left sided with high lesions

Question 500

What are 5 causes of Chylothorax?

Answer 500

1. Trauma 2. Tumour 3. Inflammatory filariais- TB 4. Primary lymphatic- lymphangioma, lymphangiomyomatosis 5. Idiopathic

Question 501

What are the 3 causes of a dense hemithorax keeping the mediastinum central?

Answer 501

1. Consolidation 2. Pleural effusion 3. Mesothelioma

Question 502

What are 4 causes of a dense hemithorax causing the mediastinum to move towards?

Answer 502

1. Collapse 2. Post pneumonectomy 3. Lymphangitis carcinomatosa 4. Pulmonary agenesis & hypoplasia

Question 503

What are 2 causes of a dense hemithorax causing the mediastinum to move away?

Answer 503

1. Pleural effusion | 2. Diaphragmatic hernia

Question 504

What are 3 causes of a white lung on CXR?

Answer 504

1. Collapse 2. Effusion 3. Pneumonectomy

Question 505

What would you do for a secondary spontaneous pneumothorax (SSP)?

Answer 505

- Admit all patients for observation +/- drain | - Oxygen

Question 506

What would you do for a primary spontaneous pneumothorax (PSP)?

Answer 506

- Discharge if not symptomatic - Worsening advice, flying (radiological resolution), scuba diving (after bilateral pleurectomy), heavy lifting - Early review for repeat CXR - Smoking advice

Question 507

What 4 things should you do once the pneumothorax drain is in?

Answer 507

1. Chest drain chart (bubbling, swinging, twisted?) 2. Remove 24h after bubbling has stopped 3. Usually no need for post removal CXR 4. Surgical emphysema usually only “cosmetic”

Question 508

What 3 things should you do if the chest drain has persistent bubbling?

Answer 508

1. Suction 2. Larger drain 3. Cardiothoracic surgeons

Question 509

Describe the recurrence rate of a pneumothorax?

Answer 509

- 40% at 1 year - Increased in smokers - Elective referral for surgical (not medical) pleurodesis

Question 510

Describe the presentation of a secondary spontaneous pneumothorax (SSP)?

Answer 510

- Can be very symptomatic with small pneumothorax | - Look carefully, if doubt about bulla vs pneumothorax consider CT

Question 511

What is a Thopaz Unit?

Answer 511

Digital Chest Drain suction

Question 512

What would you use in ambulatory management of a pneumothorax?

Answer 512

"Pleural vent" drain

Question 513

What is the normal volume of pleural fluid?

Answer 513

<15 ml

Question 514

Describe normal pleural fluid?

Answer 514

Clear, serous fluid, few cells

Question 515

Describe the diagnosis of pleural effusion?

Answer 515

- Difficult to detect < 500ml clinically | - CXR may only show blunting of the costophrenic angle

Question 516

How does a pleural effusion present?

Answer 516

Asymptomatic or associated with SOB, cough, pleuritic chest pain or referred pain to the shoulder/abdomen

Question 517

List the 6 clinical signs of a pleural effusion?

Answer 517

1. Reduced chest expansion 2. Reduced tactile vocal fremitis 3. Stony dull percussion note 4. Quiet breath sounds 5. Bronchial breathing above fluid level 6. Rub with pleural inflammation

Question 518

How do pleural effusions arise?

Answer 518

When the balance between pleural fluid production & absorption has been disturbed

Question 519

List the 5 mechanisms of a pleural effusion?

Answer 519

1. Increased hydrostatic pressure (CCF) 2. Decreased osmotic pressure (hypoalbuminaemia) 3. Increased vascular permeability (pneumonia) 4. Decreased lymphatic drainage (mediastinal carcinomatosis) 5. Increased intra-pleural negative pressure (atelectasis)

Question 520

What is a rare mechanism of pleural effusion?

Answer 520

Transdiaphragmatic passage of ascites from abdomen, chyle (chylothorax), blood (haemothorax)

Question 521

List the 5 approaches to a patient with pleural effusion?

Answer 521

1. Clinical History 2. Clinical features 3. Pleural fluid analysis 4. Further imaging 5. Pleural biopsy

Question 522

Describe bilateral pleural effusions?

Answer 522

- Cause usually obvious - Usually transudate - No need to sample initially - Treat underlying cause

Question 523

What can cardiac failure cause?

Answer 523

Unilateral effusion, particularly on the right

Question 524

What should you consider when investigating a pleural effusion?

Answer 524

Liver disease (very low protein- do not drain)

Question 525

What can chronic transudate become?

Answer 525

Exudate

Question 526

Describe unilateral pleural effusions?

Answer 526

- Many causes (e.g. infection, malignancy, PTE, inflammatory, TB) - US can look for septations & suggest infection - Involve respiratory team early

Question 527

What are the initial investigations for a unilateral effusion?

Answer 527

- Evidence of sepsis - Classical radiological appearance of empyema - USS characteristics - Needs sampling & drainage (pleural fluid pH)

Question 528

What are 5 things you would consider if the patient had a unilateral effusion & no sepsis?

Answer 528

1. Contrast CT chest/ abdo/ pelvis 2. Consider breast/ gynaecological malignancy 3. Asbestos history 4. Consider TB 5. Liver disease

Question 529

What is pleural fluid sampling always under?

Answer 529

US guidance (real time)

Question 530

Describe the minimum pleural fluid sampling?

Answer 530

- 100ml to cytology - Biochemistry for LDH/ glucose/ protein (Light’s criteria) - Ideally paired serum samples - Microbiology including TB culture, send in blood culture bottles if empyema suspected

Question 531

How should you drain pleural fluid for sampling?

Answer 531

- Remove 1 litre if symptomatic then stop unless poor performance status - Do not drain to dryness

Question 532

Describe a transudate fluid?

Answer 532

- Protein < 30 g/l - LDH < 2/3 upper limit of normal value for serum LDH - Often Bilateral - Usually clear

Question 533

Describe an exudate fluid?

Answer 533

- Protein > 30 g - LDH > 2/3 upper limit of normal value for serum LDH - Pleural / serum protein ratio > 0.5 - Pleural LDH / serum LDH ratio > 0.6 - Usually unilateral - Clear, cloudy or blood-stained

Question 534

What criteria specifies an exudate fluid?

Answer 534

Light's criteria

Question 535

What are the 4 common causes of a transudate effusion?

Answer 535

1. Cardiac failure 2. Hepatic cirrhosis 3. Nephrotic syndrome 4. Hypoalbuminaemia

Question 536

What are the 4 common causes of an exudate effusion?

Answer 536

1. Bacterial pneumonia 2. Malignancy 3. Mesothelioma 4. TB

Question 537

What is a medical thoracoscopy?

Answer 537

- Procedure of examining the parietal pleura, visceral pleura & diaphragm with a thoracoscope - Rigid or semi-rigid flexible thoracoscope

Question 538

What is a Medical Thoracoscopy indicated in?

Answer 538

Undiagnosed cytology negative pleural effusions

Question 539

Describe what a medical thoracoscopy shows?

Answer 539

- Direct visualisation of the pleural surface - Biopsy of areas which appear abnormal - Therapeutic manoeuvres e.g. complete fluid drainage & pleurodesis during the same procedure

Question 540

What is the % diagnostic rate for malignant pleural disease via medical Thoracoscopy?

Answer 540

~90%

Question 541

Describe the medical thoracoscopy procedure?

Answer 541

- Oramorph/ atropine premed, 2-4mg midazolam - Patient in lateral decubitus position - Spot marked with ultrasound - Local anaesthetic (20ml 1% lidocaine) - Creation of pneumothorax - Blunt dissection, port inserted - Drainage of fluid with suction catheter - Inspection of pleural surface - Size 24-28 chest drain which is removed once lung re-expanded

Question 542

What is the name for a primary pleural malignancy?

Answer 542

Mesothelioma

Question 543

Describe the prognosis of mesothelioma?

Answer 543

Poor prognosis, treatment supportive

Question 544

What is a common site for metastatic spread?

Answer 544

The pleura- esp breast, ovarian, bowel, renal & lymphoma

Question 545

What would you traditionally do for a pleural malignancy?

Answer 545

Insert drain followed by medical (talc slurry) pleurodesis on ward

Question 546

What are the 5 problems with the traditional treatment of pleural malignancy?

Answer 546

1. Poor distribution of talc- frequently fails 2. May not come back anyway 3. When to do in relation to chemotherapy 4. Trapped lung 5. High output effusion

Question 547

What are the 6 questions to ask before drainage of a pleural effusion in malignancy?

Answer 547

1. Is the diagnosis secure? 2. Do I need to send more samples? 3. How symptomatic is the patient? 4. What is the performance status? 5. Has the patient previously felt better after drainage? 6. Did the patient find the procedure uncomfortable before?

Question 548

What are the 4 management options for a malignancy pleural effusion?

Answer 548

1, Drain to dryness once & discharge (if diagnosis secure & already have tissue) 2. Medical pleurodesis 3. Thoracoscopic pleurodesis 4. Indwelling pleural catheter (IPC)

Question 549

List the 7 patient factors for getting an indwelling pleural catheter?

Answer 549

1. Prognosis, performance status 2. Patient preference 3. Symptomatic benefit from drainage 4. Rate of accumulation 5. Trapped lung 6. Timing of chemotherapy 7. Evidence

Question 550

What do upto 50% of pneumonias have?

Answer 550

Associated effusion (parapneumonic)

Question 551

Describe a complex parapneumonic effusion?

Answer 551

- pH <7.2 - LDH >1000 - Glucose <2.2 - Loculated on ultrasound

Question 552

What is an Empyema?

Answer 552

Presence of pus or bacteria

Question 553

Describe the prognosis of an Empyema?

Answer 553

- 15% mortality - 15-40% require surgery - Median length of stay 15 days

Question 554

Describe the investigations of a pleural infection?

Answer 554

- Initial radiology can be suggestive - Effusion with signs of sepsis - Consider if patient with pneumonia failing to improve (USS)

Question 555

How do you manage an Empyema?

Answer 555

- Small bore chest drain (12-16F) - Larger drains are painful & no more effective - Frequent sterile saline flushes - IV antibiotics - DVT prophylaxis

Question 556

What medication would you give to manage an Empyema?

Answer 556

Fibrinolytics - Streptokinase - DNA ase & TPA (alteplase)

Question 557

What are the 3 key messages to remember for a pleural effusion?

Answer 557

1. If bilateral treat cause & repeat imaging 2. Do not drain at initial presentation if unilateral 3. Discharge early 4. Consider infection

Question 558

What are the 2 key messages to remember for a malignant pleural effusion?

Answer 558

1. Involve respiratory - various options | 2. Go by symptoms not presence of fluid

Question 559

What are the 2 key messages to remember for a pleural infection?

Answer 559

1. Maintain index of suspicion, even if CXR non diagnostic | 2. Fibrinolytics in selected cases