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MSRA 2022 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are the criteria in the CURB 65 score for pneumonia severity?

A

C - confusion = +1
U - serum Urea >7 mmol/L = +1
R = resp rate greater than or equal to 30 = +1
B = BP systolic <90 or diastolic <60 = +1
Age 65 or older = +1

0/1 = mild = consider OP Mx
2 = moderate = consider iP or OP with close-follow up
3 or more = severe = IP Mx, may require ITU input

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2
Q

For a patient recently treated as an inpatient for a pneumonia, how should they be followed-up in the community as per NICE guidelines?

A

CXR in 6-12 weeks to assess for resolution of consolidation / assess for an underlying malignancy which may be missed during the acute infective phase.

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3
Q

What is the classical presentation of COPD?

A

Smoking history +

  • EXERTIONAL SOB
  • chronic productive cough / sputum production
  • frequent winter bronchitis
  • wheeze
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4
Q

What is the grading system that should be used to grade breathlessness in COPD?

A

The MRC Dyspnoea Scale:

Grade I - not breathless except after strenuous exercise
Grade II - SOB when hurrying or on an incline
Grade III - has to stop to catch breath even at own pace on the flat
Grade IV - has to stop to catch breath after 100 metres / a couple of minutes
Grade V - Too breathless to leave the house / breathless when dressing

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5
Q

What is the 1st line diagnostic test for COPD?

A

Pre + post bronchodilator spirometry
Diagnostic criteria = post-bronchodilator FEV1/FVC ratio <0.7

At the time of diagnosis they should also get:

  • a CXR (t exclude other pathologies)
  • FBC to check for anaemia / polychythaemia
  • BMI calculated
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6
Q

How should you manage incidental findings of emphysema or chronic airways disease on a CXR or CT?

A

Consider referral for lung MDT discussion.

If asymptomatic, normal spirometry and current SMOKER -> provide smoking cessation support, advise the presence of emphysema on a CT in an independent risk factor for lung cancer, advise them to return if they develop respiratory symptoms.

If asymptomatic, normal spirometry and NON-SMOKER -> ask about fam Hx of lung or liver disease or alpha-1-antitrypsin deficiency, reassure unlikely to get worse but that still an independent risk factor for emphysema.

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7
Q

What additional inv should you consider in patients suspected to have COPD but with some features of asthma?

A

Serial home peak flow measurements

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8
Q

When should you check serum alpha 1 anti-trypsin?

A

Early onset
Minimal or no smoking Hx
Strong family Hx

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9
Q

When should you check Transfer Factor for Carbon Monoxide (TLco)

A

TLco = the gas transfer test = tests how well your lungs uptake the air = breath in small amounts of helium and carbon monoxide

Do TLco:
If symptoms are disproportionately bad compared to the spirometry values
OR
If assessing suitability for lung volume reduction surgery

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10
Q

What are the spirometry patterns in restrictive versus obstructive lung disease

A

FEV1 = expired air in 1st second = REDUCED IN BOTH OBSTRUCTIVE AND RESTRICTIVE.
FVC = total expiratory capacity = NORMAL in obstructive, reduced in restrictive
FEV1/FVC ratio = represents the efficiency of the lungs -> NORMAL in restrictive, reduced in obstructive

Obstructive:
FEV1 = reduced. FVC = normal. FEV1/FVC ratio = reduced

Restrictive:
FEV1 = reduced. FVC = reduced. FEV1/FVC ratio = normal

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11
Q

What features of spirometry suggest asthma as either an alternative or concurrent diagnosis with COPD?

A

Classically, the FEV1 and FEV1/FVC ratio improves dramatically post-bronchodilator in asthmatics. It may improve in COPD but the FEV1/FVC ratio will remain <0.7 after bronchodilation. The greater the rise in FEV1, the more likely there is a component of asthma.

CLINICALLY SIGNIFICANT COPD IS NOT PRESENT IF THE FEV1 AND FEV1/FVC RATIO RETURN TO NORMAL WITH DRUG THERAPY (EITHER BRONCHODILATORS OR ORAL STEROIDS`)

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12
Q

What are clinical features that suggest asthma as a diagnosis rather than COPD?

A
  • Symptoms < age 35
  • Significant diurnal variation in symptoms
  • Night time waking with wheeze / SOB
  • don’t have chronic productive cough
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13
Q

What are the 2010 NICE guidelines on grading airflow obstruction from spirometry values in COPD?

A

COPD = heterogenous, airflow obstruction - staging alone doesn’t signify the severity of disease, also take into account MRC dyspnoea scale, COPD Assessment Test (CAT) score on symptom burden, freq of admissions etc.

Airflow obstruction staging: (in all stages the post-bronchodilator FEV1/FVC ratio must be <0.7 otherwise it’s not COPD!)
Stage I - FEV1 > 80% of predicted (mild)
Stage II - FEV1 50 - 80% (moderate)
Stage III - FEV1 30-50% (severe)
Stage IV -FEV1 < 30% (very severe)

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14
Q

What are indicators to refer to a specialist for patients with COPD?

A

Diagnostic uncertainty, onset < 40 years, alpha 1 antitrypsin deficiency, severe COPD, onset of cor pulmonale, needs consideration for 02 therapy/home nebs or oral steroids, to assess suitability for pulmonary rehab or lung reduction surgery (eg in bullous disease), frequent infections (to exclude bronchiectasis), haemoptysis

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15
Q

What is the pathway of managing stable COPD?

A

For all: smoking cessation advice, pneumococcal vaccine + annual flu vaccine, refer for pulmonary rehab if indicated (those that are functionally impaired by COPD including those MRC grade 3 and above, recent hospital admission for acute exacerbation -> PULMONARY REHAB NOT SUITABLE FOR THOSE WITH UNSTABLE ANGINA OR RECENT MI OR UNABLE TO WALK

Start inhaled therapies only IF needed to relieve SOB/exercise intolerance AND the pt adequately trained in inhaler technique.

1) PRN SABA [Salbutamol, Albuterol, Terbutaline] or SAMA [slower onset of action than SABAs (30-60 mins), duration of action up to 6 hrs] [Ipratropium].
2) If still having exacerbations / troubled by symptoms then consider whether features of asthma / steroid responsiveness.

-> Asthmatic / Steroid-responsive Features:
LABA + Inhaled Corticosteroid
(If continues to have exacerbations / symptoms add-in a LAMA)

-> No asthma/steroid-responsive features:
LABA + LAMA
(if persistent daily symptoms -> consider 3 month trial of adding in ICS)
(if 1x severe or 2x moderate annual exacerbations -> start ICS)

3) Once on maximal trio of inhalers other add-ons can consider are: * home nebs * oral theophylline - caution in the elderly, need serum theophylline levels checked 1-2 a year * oral mucolytics (carbocysteine, acetylcysteine)

Tx with antioxidants (alpha-tocopherol or beta carotene) or anti-tussive therapy is NOT recommended in COPD.

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16
Q

How do you calculate pack years in smoking history?

A

Pack years = (No of cigs smoked per day / 20) x No of years smoked.

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17
Q

Examples of SABAs

A

Salbutamol, Albuterol, Terbutaline

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18
Q

Examples of SAMAs

A

Ipratropium

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19
Q

Examples of LABAs

A

Salmeterol, Formoterol, Indacaterol, Arformoterol

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20
Q

Examples of LAMAs

A

Tiotropium, Glycopyronium bromide, Aclidinium Bromide

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21
Q

Examples of ICS

A

Beclamethasone, Budesonide, Fluticasone, Mometasone

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22
Q

What features suggest asthmatic features / steroid responsiveness when considering treatment for COPD?

A

1) Prev dx of asthma or atopy
2) Diurnal variation (>20%) in PEF
3) High eosinophil count
4) Significant variation in FEV1 (>400ml) over time

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23
Q

When should you consider antibiotic prophylaxis for patients with COPD?

A

Consider abx prophylaxis (with Azithromycin three times a week) IF:
* Non-smoker
AND
* Optimised inhaler regime
AND
* 4 or more IECOPD/year or prolonged IECOPDs with purulent sputum production or exacerbations resulting in hospitalisation

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24
Q

What tests should be done before starting a COPD patient on prophylactic azithromycin / antibiotics?

A

1) CT Thorax to exclude bronchiectasis
2) Sputum culture to assess for atypical / resistant bacteria
3) Optimised sputum clearance technique
4) ECG (to assess QTc) and baseline LFTs are needed before starting Azithromycin -> must advice pts on small risk of tinnitus + hearing loss

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25
Q

What are features that indicate referral to be considered for long-term oxygen in COPD

A
  • Polycythaemia
  • Cyanosis
  • Severe airflow obstruction (FEV1 <30%)
  • Peripheral oedema / ^ JVP / pulmonary HTN (Signs of cor pulmonale)
  • Sats 92% or less on air
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26
Q

What investigation should be done to assess whether COPD patient is eligible for long-term 02?

A

2 ABGs at least 3 weeks apart

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27
Q

What are the eligibility criteria for long term 02 in COPD?

A
  • NON-SMOKER
    and
  • pa02 < 7.3
    OR pa02 7.3 - 8 plus polycythaemia, peripheral oedema or pulmonary hypertension
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28
Q

What are the diagnostic features of Acute Severe Asthma?

A

Any one of:
PEF 33-50% of best/predicted
RR 25 or more in adults, >30 in children >5 and >40 in children under 5.
HR >110 in adults, >125bpm in children over 5, or > 140bpm in children under 5.
Unable to complete full sentences

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29
Q

What are the diagnostic features of Life-Threatening Asthma?

A 
Any one of: 
PEF <33% of best/predicted 
SP02 <92% 
pa02 <8 kPa
Normal C02 (normally low initially in asthmatics as hyperventilating) 
Reduced consciousness 
Exhaustion 
Cyanosis 
Silent chest 
Hypotension
Arrythmia
30
Q

What are the diagnostic features of Near-Fatal Asthma?

A

Raised PaC02

Requiring mechanical ventilation with raised inflation pressures

31
Q

What are the key differences in presentations between asbestosis and malignant mesothelioma?

A

Asbestosis actually requires more PROLONGED exposure to asbestos in order to contract it and thus is RARER

Malignant mesothelioma = pleural thickening on CT
Asbestosis = pleural scarring

32
Q

what is the typical presentation of sarcoidosis on CXR?

A

Bilateral HILAR lymphadenopathy

33
Q

What is the typical presentation of Churg-Strauss / Eosinophilic Granulomatosis with Polyangitis

A

Autoimmune vasculitis. pANCA positive.
Triad of asthma + eosinophilia + vasculitis

Often initially presents as sinusitis / worsening of allergy symptoms then they develop asthma and systemic vasculitic symptoms.

34
Q

exudative v transudative pleural effusion?

A

E = Extremely bad, Elevated protein
= protein > 35 g/L
Exudative = malignancy, infection, inflammation

Transudative = heart failure, liver failure, renal failure
= protein < 25

35
Q

What is the epworth score used for?

A

to measure daytime sleepiness eg in obstructive sleep apnoea
0-24. 0-10 = normal.
Anything over 10 suggests excessive daytime sleepiness with increasing severity. ,

36
Q

What is the difference in presentation of obesity hyperventilation syndrome and obstructive sleep apnoea?

A

Obesity hyperventilation syndrome = daytime hypercapnea + prolonged periods of hypoventilation overnight.

Obstructive sleep apnoea = ^ daytime sleepiness (epworth scale > 10)

37
Q

What is the gold standard imaging modality for patients with lung malignancy

A

Contrast CT / CT PET is generally the best for lung malignancy.

MRI is only used for Pancoast tumours or when spinal canal invasion is suspected.

38
Q

What is the 1st line action in someone with suspected tension pneumonthorax on clinical examination?

A

Needle decompression - insertion of large-bore cannula into 2nd intercostal space in the midclavicular line.

39
Q

What is the classical presentation of whooping cough (pertussis) and when are antibiotics most useful?

A

1) Catarrhal stage -> symptoms of upper resp tract infections runny nose fever etc -> this is when abx are of use, after this initial phase, conservative mx only
2) coughing / whooping stage
3) convalesence

40
Q

What is the typical presentation of obstructive sleep apnoea?

A

More common in MEN than women

Symptoms = daytime sleepiness, reduced libido, morning headache, loud snoring, decreased cognitive performance

41
Q

What are the most common causative organisms in community acquired pneumonia?

A

1) Strep pneumoniae (especially in children >2)
2) Haemophilus influenzae
3) Mycoplasma pneumoniae

42
Q

What are the most common causative organisms in hospital acquired pneumonia?

A

1) Gram negative enterobacteria

2) Staph aureus

43
Q

Typical presentation of Q fever / coxielli burnetti ?

A

Cattle/sheep/goats transmission
Pneumonia + generalised myalgia + GI upset
1st line abx -> macrolide (azithromycin, clandamycin -> macrolides are normally first line for atypical pneumonias!)

44
Q

Typical presentation of mycoplasma pneumonia?

A

atypical pneumonia with prolonged prodrome
Complications = 1) cold agglutins 2) haemolytic anaemia
Tx - macrolides

45
Q

Typical presentation of goodpasture’s disease

A

Pulmonary alveolar haemorrhage (bilateral pneumonia + haemoptysis) + acute glomerulonephritis (haematuria)

46
Q

Typical presentation of pneumocystis jiroveci?

A

HIV/AIDs defining illness

‘silent’ breathless - chest clear on auscultation

47
Q

Typical presentation of legionella / legionaires disease?

A

Transmitted via hot water systems / spas

Presents w/ pneumonia + confusion + diarrhoea

48
Q

Typical presentation of Psittacosis / bird fanciers lung ?

A

Exposure to birds, rising titre of COMPLEMENT FIXING ANTIBODY

49
Q

Typical presentation of bronchiectasis?

A

Triad of 1) chronic cough 2) frequent infections 3) lots and lots of sputum (may have haemoptysis)
CXR - shows peribronchial fibrosis
Gold standard Dx = High resolution CT Thorax

50
Q

1st line test for cystic fibrosis?

A 
Sweat test (sweat chloride levels >60 mmol /L = supports diagnosis)
(-> genetics: DF508 most common mutation in CF)
51
Q

Tx of legionaires disease? (atypical pneumonia)

A

Macrolide (azithromycin or clarithromycin)
If v severe can add in rifampicin for the first few days
presentation = pneumonia + confusion + diarrhoea/GI upset + hyponatraemia + derranged LFTs

52
Q

Typical presentation of klebsiella pneumonia?

A

HIGH fever + recurrent jelly (blood tinged) sputum

Common in alcoholics, diabetics and immunocompromised

53
Q

Typical presentation of mycoplasma pneumonia?

A

Common in populated areas eg student halls

Associated with erythema multiforme rash (target lesions!) and haemolytic anaemia

54
Q

Side effects of pyrazinamide (as part of RIPE for TB) ?

A

Arthralgia
^ uric acid levels -> can precipitate gout flares
Hepatitis

55
Q

Typical presentation of avian flu / bird flu?

A

Influenza type A
human to human transmission NOT possible = bird -> human transmission only
antivirals (tamiflu) effective IF given in the initial 48 hrs

56
Q

Which condition presents with red/blue nodules over the nose and ears (lupus pernio) ?

A

SARCOIDOSIS

virtually pathopneumonic

57
Q

Type I versus Type II respiratory failure?

A

Type I - low 02, normal or low C02
(occurs due to damage to lung tissue but the remaining healthy tissue is still able to excrete the C02 = pneumonia, ARDS, Covid-19, non-carcinogenic and carcinogenic pulmonary oedema)
Type II - low 02, high C02
(COPD most common, but also chest wall deformities, Guillain-Barre, central resp depression (eg opioid overdose)

58
Q

Adult pathway for asthma management?

A

1) PRN SABA
2) Regular low-dose ICS + PRN SABA
3) Leukotriene receptor antagonist OD (Montelukast) + regular low dose ICS + PRN SABA
4) low-dose ICS + LABA +/- continuing montelukast + PRN SABA
5) MART (maintenance + reliever regime = ICS + a fast-acting LABA that mitigates the need for a separate SABA) +/- montelukast
6) increase the ICS to moderate dose
7) either increase the ICS to high dose OR add-in theopylline OR add-in muscarinic antagnoist (tioptropium etc) -> specialist

59
Q

Child pathway for asthma management ?

A

1) PRN SABA
2) Paediatric dose ICS + PRN SABA
3) Add-in Montelukast
4) If doesn’t work -> STOP the montelukast -> ICS + LABA
5) If doesn’t work -> MART regime of ICS + LABA
6) -> increase the iCS component to moderate paediatric dose
7) specialist help

60
Q

typical presentation of allergic bronchopulmonary aspergillosis?

A

Pts with CF or asthma
-> germination of the airways with aspergillosis
get ^ eosinophils + IgE

61
Q

typical presentation of histoplasmosis?

A

inhalation of the histoplasma fungi from soil or bat droppings
Presents with dry URTI / SOB
^ risk of immunocompromised

62
Q

typical presentation of aspergilloma?

A

IMMUNOCOMPROMISED or CAVITATING LUNG DISEASE (emphysema or TB)

-> haemoptysis + mass in the upper lobe on CXR

Tx -> Itraconazole

63
Q

typical presentation of heroin misuse?

A

Sweating + leg cramps + pinpoint pupils

At risk of ARDs

64
Q

What criteria would make you refer urgently rather than routinely to sleep clinic in suspected Obstructive Sleep Apnoea?

A
  • Pregnancy
  • A job that requires daytime vigilance for safety
  • Non-arteritic ischaemic optic neuropathy
  • Unstable cardiovascular disease
  • Undergoing pre-op assessment for major surgery
65
Q

Current guidance on diagnosis and management of DVT?

A

DVT -> Well’s Score for DVT

  • > Wells Score 2 or more -> DVT is likely -> USS doppler if can do within 4 hours, if not then D-Dimer + interim anticoagulation + USS within 24 hrs
  • > if USS +ve -> continue anticoagulation
  • > if USS -ve -> STOP anticoagulation and do D-dimer if not already -> if D-dimer positive, then repeat scan in 6-8 days, if negative no further action

Well’s Score 1 or 0 -> DVT unlikely -> D-Dimer with result within 4 hours (if can’t get the result that quickly then interim anticoagulation)

  • > D-dimer positive -> USS within 4 hours OR interim anticoagulation + USS within 24 hrs
  • > D-Dimer negative -> stop any anticoagulation
66
Q

Well’s Score for DVT?

A

1 for each!

  • Active cancer
  • Paralysis/paresis or recent plaster of lower leg
  • Bedridden for 3 days + or major surgery < 12 weeks
  • localised tenderness
  • calf diameter 3 or more cm larger than the other
  • entire leg swollen
  • pitting oedema confined only to the affected leg
  • superficial non-varicose veins
  • prev documented DVT
67
Q

Diagnosis of PE?

A

PE suspected -> Well’s Score for PE

-> Well’s score 5 or more -> PE likely -> immediate CTPA or interim anticoagulation while waiting
CTPA +ve -> continue Tx
CTPA -ve -> if suspicion of DVT then USS doppler, if not stop anticoagulation

-> Well’s score is 4 or less -> PE unlikely -> D-Dimer with results within 4 hours
D-dimer positive -> immediate CTPA / interim anticoag
D-dimer negative -> nil further action

68
Q

Well’s score for PE?

A 
\+3 if signs/symptoms of DVT 
\+3 if another diagnosis is unlikely 
\+1 if haemoptysis 
\+1 if active cancer 
\+1.5 if bedridden 3+ days or surgery <4 wks 
\+1.5 for tachycardia >100 
\+1.5 for prev DVT/PE
69
Q

Choice and duration of anticoagulation in DVT / PE?

A

If PE + haemodynamically unstable -> unfractionated heparin infusion + consider thrombolysis

if not, 1st line = Apixaban + Rivaroxaban
Duration for all = 3 months then review (if active cancer = 3-6 months)

if renal impairment:
if CrCl if >15 can still have DOAC
If CrCl is <15 -> offer LMWH, UFH or warfarin with LMWH/UFH to bridge until INR >2.

If triple positive diagnosed antiphospholipid syndrome:
1st line -> Warfarin (With LMWH to bridge until INR >2)

70
Q

Management of DVT / PE in pregnancy?

A

As soon as VTE suspected in pregnancy, start LMWH

There is no Well’s score equivalent. Cannot use D-Dimer.

If suspected DVT or suspected PE with signs/symptoms of DVT -> USS doppler -> if positive continue treatment for DVT/PE without need for chest scan

if suspected PE with no signs/symptoms of DVT -> CXR + ECG -> if CXR if abnormal, then CTPA is preferred.

VQ scan has slightly higher rate of childhood cancer than CTPA but lower risk of maternal breast cancer. The absolute risks of both are small.
CTPA is preferred if maternal agreement.

If massive PE with haemodynamic instability -> UFH infusion + senior consideration re thrombectomy

LMWH should be continued for the remainder of pregnancy and for at least 6 weeks after (until a minimum of 3 months has been given)

71
Q

Definition of hypoxia and hypercapnoea on ABG?

A 
Hypoxia = Pa02 <8 kpa 
Hypercapnoea = PaC02 >6 Kpa

MSRA 2022 (23 decks)

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