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Respiratory > Core > Flashcards

Core Flashcards

1
Q

COPD:

  1. What are the main causes of COPD? (3)
  2. Which conditions does COPD encompass (2) and compare them in the context of a) alveolar ventilation b) type of resp. failure each leads to c) The extent of breathlessness and cyanosis of each
  3. What are some signs of hyperinflation? (3)
  4. What is cor pulmonale? How does it arise?
  5. What are some signs of cor pulmonale? (3)
  6. What are the main complications of COPD? (4)
  7. What is the westermark sign?
  8. What FEV1% determines if COPD is mild, moderate, severe, v severe?
  9. Who is eligible for home oxygen therapy with COPD? (4)
A
    • Smoking
    • a1 anti-trypsin deficiency
    • Occupational exposure
  2. Chronic bronchitis = decreased alveolar ventilation, develops T2 resp failure, cyanosed but not breathless
    Emphysema = increased alveolar ventilation, develops T1 resp. failure and breathless but not cyanosed
  3. Reduced circosternal distance, loss of cardiac dullness and displaced liver edge
  4. Impaired RV function due to increased circulatory resistance in the pulmonary artery. States of chronic hypoxia = pulmonary artery vasoconstriction
  5. Raised JVP, oedema and loud P2 (second HS)
  6. Acute exacerbations +/- infection
    Polycythemia
    PTX
    Cor pulmonale
  7. Area of increased translucency - sign of peripheral hypovolaemia due to impaired vascularisation
  8. Mild = >80%, moderate 50-79%, severe 30-49%, v severe = <30%
9. LTOT is offered if PaO2 <7.3kPa 
Or 
PaO2 7.3-8kPa and one of the following: 
- secondary polycythaemia 
- peripheral oedema 
- pulmonary hypertension
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2
Q

PE:

  1. What are the RFs for PE? SPASMODICAL
  2. What is a Wells score? What do the scores mean?
  3. What are the steps in managing a suspected PE? (5)
  4. What is the ongoing management after a provoked and unprovoked PE?
  5. What would suggest a critically unwell patient with a massive PE?
  6. What type blood gas abnormality is seen with PE?
  7. Who is eligible for IVC filters?
  8. How do you differentiate it from other cardio and resp conditions?
  9. What is the preferred Ix for those with renal impairment?
  10. What should you do if there is a high suspicion of PE but delay in getting a scan?
A 
Sex: F 
Pregnancy 
Age 
Surgery 
Malignancy 
Oestrogen (OCP/HRT) 
DVT - biggest RF (from proximal or iliac veins) 
Immobility 
Colossal size 
Antiphospholipid antibody 
Lupus anticoagulant
  1. Assesses the risk of a PE
    <4 = d-dimer (if positive then CTPA)
    4+ = CTPA
  3. O2 - 100% non-rebreathe
  4. Analgesia - morphine + metclopramide
  5. Anticoagulation - DOAC, LMWH followed by dabigatran or warfarin (2nd line)
  6. Thrombolysis - if hypotensive + massive PE
  7. SBP >90mmhg = warfarin, <90mmhg = 500ml colloid
  8. Determine if PE is provoked (i.e. VTE post surgery or flight) or unprovoked:

Provoked VTE requires 3mth anticoagulation
Unprovoked VTE requires 6mth anticoagulation

DVT prophylaxis can also be offered

  1. SBP <90 or fall of 40mmhg
  2. Respiratory alkalosis
  3. Those with repeated PE despite anticoagulation
  4. Normal ECG and clear chest
  5. V/Q scanning
  6. Start apixiban until scan becomes available.
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3
Q

COPD management:
Stable:
1. What are the conservative measures? (3)
2. What is the first line medical management?
3. If they are still breathless after the initial medical management, what is the next level of management?

Acute exacerbation:

  1. What are the main causes? (2)
  2. What would make you consider admission? (5)
  3. If admission is not required, how would you manage the exacerbation? (3)
  4. What are the four main steps to managing an acute exacerbation in hospital?
  5. How is oxygen administrated for COPD exacerbations? What are the target sats?
  6. When would you consider BiPaP? (2)
A
  1. Stop smoking, review 1-2X per year and pneumococcal (one-off) + influenza vaccines (annual)
  2. SABA or SAMA
  3. Do they have asthmatic features (e.g. eosinophilia, diurnal variation, variable FEV1)?
    Y = LABA + ICS (LABA + LAMA + ICS if still breathless)
    N = SABA + LABA + LAMA
  4. Viral URTI (rhinovirus), H influenzae (most common bacterial)
  5. Admit if there are any signs of increased work of breathing, cyanosis, confusion, sats <90% and rapid onset
  6. Increase dose or frequency of SABA/SAMA + oral pred 30mg 7-14 days, Abx if signs of bacterial infection (purulent sputum + consolidation)
  7. Controlled O2 therapy
  8. Nebulised bronchodilators - salbutamol + ipratropium
  9. Steroids - IV and PO hydrocortisone + pred 7-14 days
  10. Abx - amox/clari/doxycycline 200mg stat then 100mg for 5 days
  11. 24% O2 via Venturi - 88-92%
  12. BiPaP if pH <7.35 or RR >30.
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4
Q

PTX:

  1. What are the causes of a PTX? (3)
  2. Who are spontaneous PTXs most common in? (2)
  3. What are some iatrogenic causes of PTX? (3)
  4. What is the life threatening aspect of tension PTX?
  5. Why is CXR not done immediately if tension PTX is suspected?
  6. What signs would point towards PTX?
  7. How do you manage a tension PTX? (2)
  8. How do you manage a primary PTX?
  9. How do you manage a secondary PTX? (2)
  10. What is the main complication of aspiration/chest drain insertion? When does it occur? (2)
A
  1. Spontaneous, Trauma, Iatrogenic
  2. Primary = tall thin male smokers
    Secondary = underlying lung disease
  3. Central line insertion, +ve pressure inflation and biopsies
  4. Compression of great vessels = arrest
  5. Delays treatment
    • Reduced chest expansion
      - Reduced breath sounds
      - Resonant percussion
  7. Large bore (14-16G) needle or syringe (venflon) - 2nd intercostal space mid clavicular line then chest drain
  8. SOB and/or rim >2cm = aspirate, if successful then consider d/c - if unsuccessful then chest drain

No SOB or rim <2cm = consider d/c

  1. > 50y/o and >2cm rim and/or SOB: Y = chest drain N= aspirate (if successful admit for 24hrs, otherwise chest drain)

If rim is 1-2cm then aspirate

If the rim is <1cm then prescribe oxygen and admit for 24hours

  1. Re-expansion pulmonary oedema - when >1L is drained in 6hours or over 2.5L in total
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5
Q

Pneumonia:

  1. What are the three most common causes of CAP? (3)
  2. Which CAP is more common in COPD? Which presents with a gradual onset dry cough?
  3. Which CAP is more common in DM and alcoholics, presenting with red jelly-like sputum?
  4. What are the main causes of HAP? (2) How long after admission do they typically present?
  5. Which conditions increase the risk of aspiration pneumoniae? (3)
  6. Which Abx would you give for pneumonia with CURB65 of 0 or 1?
  7. Which Abx would you give for pneumonia with CURB65 or 2?
  8. Which Abx would you give for pneumonia with CURB65 of 3+?
  9. Which Abx is given for penicillin allergic patients?
  10. When would you give erythromycin in treating pneumonia?
  11. Which abnormal area can pain from pneumonia be felt?
A
  1. Step pneumoniae, haemophilus influenzae, mycoplasma pneumoniae
  2. COPD = haemophilus influenzae
    Gradual consent dry cough = mycoplasma pneumoniae
  3. Klebsiella
  4. Gram -ve enters bacteria and S. aureus, >48hours
  5. Stroke, GORD, bulbar palsy
  6. Amoxicillin
  7. Amoxicillin (and clarithromycin if atypical is suspected)
  8. Co-amox and clarithromycin
  9. Doxycycline and clarithromycin
  10. Pregnancy
  11. Upper quadrant abdo pain
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6
Q

Pneumonia complications:

  1. What are the main complications? (6)
  2. How is hypotension in pneumonia managed?
  3. Which organisms can cause empyema following pneumonia? (3)
  4. How would a lung abscess present itself? (3) What is seen on CXR? How is it managed?
  5. How is empyema managed? (2)
  6. What are the ranges for CURB65? What does the score mean?
A
  1. Resp failure, empyema, hypotension, pleural effusion, sepsis, lung abscess
  2. If SBP <90mmHg give 250ml fluid over 15 mins, if still hypotensive then central line, consider ITU for refractory hypotension
  3. Anaerobes, S aureus and gram -ves
  4. Swinging fever, foul purulent sputum, pleuritic chest pain
    CXR = cavity filled with fluid level
    Mx = Abx and surgical excision
  5. US guided chest drain and Abx
6. Confusion (AMTS <8) 
Urea (>7) 
RR (>30) 
BP (SBP <90 or DBP <60) 
65 
0-1 = home Rx 
2 = hospital Rx 
3+ = consider ITU
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7
Q

Bronchiectasis:

  1. What are the main causes of bronchiectasis? (5)
  2. What are some congenital causes of bronchiectasis? (3)
  3. Which autoimmune conditions are linked to bronchiectasis? (2)
  4. What are the four main infectious organisms in bronchiectasis?
  5. When might you suspect bronchiectasis? (4)
  6. What are the signs of bronchiectasis? (3)
  7. What are the main complications of bronchiectasis? (6)
  8. What is the best Ix for bronchiectasis? What might be seen?
  9. What might be seen on CXR (3) and spirometry?
  10. If there is an unknown causative organism, which Abx should be given?
  11. Which Abx should be given if they are pseudomonas +ve?
  12. What is the medical (2) and conservative Mx for bronchiectasis?
  13. What signs may point towards allergic aspergillosis as the cause of bronchiectasis? (2) How is it managed?
  14. When is surgery indicated in bronchiectasis? (2)
  15. When should you admit a patient with infective exacerbation of bronchiectasis? (4)
  16. When would you suspect Kartagener’s syndrome as the cause of bronchiectasis?
A
  1. Idiopathic (50%), congenital, following infection, hypogammaglobinaemia, allergic aspergillosis
  2. CF, Young’s syndrome, Kartageners syndrome
  3. RA + UC
  4. H influenzae, Strep pneumoniae, S aureus, Pseudomonas aeruginosa
  5. Chronic cough with copious purulent sputum and intermittent haemoptysis, younger patient
  6. Clubbing, coarse insp. creps, wheeze
  7. Pneumonia, pleural effusion, pulmonary HTN, cerebral abscess, significant haemoptysis, PTX
  8. High res CT - dilated thickened airways
  9. CXR = thickened bronchial walls, tramlines and rings
    Spirometry = obstructive pattern
  10. Amox
  11. Cipro
  12. Treat underlying cause:
    - Abx if infection
    - SABA neb if wheeze or breathless
    - Chest physio
  13. Eosinophilia and raised IgE - oral pred
  14. When there is uncontrollable haemoptysis or localised to one lobe
  15. If there is: confusion, increased work of breathing, cyanosis or pyrexia
  16. Presentation of bronchiectasis and dextracradia
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8
Q

Lung Cancer:

  1. What are the main types? (4)
  2. Which cancers are mainly centrally located? (2)
  3. Which cancer is peripherally located?
  4. Where are large cell cancers located?
  5. Which cancer is strongly associated with extrathoracic mets?
  6. What are some local structural complications of lung cancer? (2) How do they present?
  7. What are the ectopic hormone secretions of SCLC (2), SCC and adenocarcinoma (2)?
  8. Which tumour is associated with Horner’s syndrome? Where is it classically found?
  9. What autoimmune condition can be the result of SCLC? How does it present?
  10. After detection of mass on CXR, how would you confirm the diagnosis of a peripheral and central lung cancer?
  11. When would a radionucleotide bone scan be indicated?
  12. What is the Mx for NSCLC SI-III and patients with poor respiratory reserve?
  13. What are CIs for surgery to remove lung cancer? (4)
A
  1. SCLC, adenocarcinoma, squamous cell and large cell
  2. SCC and SCLC
  3. Adenocarcinoma
  4. Centrally or peripherally
  5. Adenocarcinoma
6. Phrenic and recurrent laryngeal nerve palsy = hoarseness 
SVC compression (syndrome) = progressive swelling and dyspnoea with distended veins on chest
  1. SCLC = Cushing’s (ACTH), SIADH (ADH)
    SCC = Hyperparathyroidism (PTH)
    Adenocarcinoma = gynaecomastia and hypertrophic pulmonary osteodystrophy
  2. Pancoast’s tumour - at the apex (top) of the lung
  3. Lambert-Eaton syndrome (autoimmune destruction of Ca2+ channels at NMJ) = proximal muscle weakness
  4. Peripheral = FNA
    Central = bronchoscopy and biopsy
  5. For suspected bony mets
  6. NSCLC SI-III = surgical excision for peripheral lesion
    Poor respiratory reserve = curative radiotherapy
  7. FEV1 <1.5L, SVC obstruction, malignant effusion, vocal cord paralysis
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9
Q

Chronic Asthma:

  1. What are the three main physiological differences which take place in asthma?
  2. Which cells are responsible for mucosal swelling and inflammation in asthma?
  3. What is the pathogenesis of chronic asthma?
  4. What type of hypersensitivity reaction is asthma?
  5. Which other diseases are associated with asthma? (3)
  6. What is the conservative Mx for asthma? TAME
  7. What are the features of asthma? (4)
  8. How is the diagnosis of asthma made in patients >17y/o? (3)
  9. How is the diagnosis of asthma made in patients 5-16y/o? (3)
  10. What should be done if an adults asthma symptoms improve when they’re not at work?
A
  1. Bronchoconstriction, mucosal inflammation and swelling, mucous plugs
  2. Mast cells and basophils
  3. Th2 cells activate IL 3-5 = mast cell, B-cell and eosinophil recruitment = airway remodelling
  4. Type 1
  5. GORD, Churg-Strauss syndrome, Allergic aspergillosis
  6. Technique (inhaler)
    Avoid (triggers)
    Monitor PEFR
    Educate (asthma nurse)
  7. Diurnal variation, eosinophilia, worse with NSAIDs and B-blockers, identifiable triggers
  8. One of:
    - FeNO test >40 part per billion (ppb)
    - FEV1:FVC ratio <0.7
    - Bronchodilator reversibility test with improvement of of 12% or more FEV1 and 200ml increase in volume
  9. One of:
    - FeNO >35ppb
    - FEV1:FVC <0.7
    - BDR of 12% or more
  10. Referred to specialist for potential occupational asthma
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10
Q

Acute Asthma Attack:

  1. What signs suggest a severe asthma attack ? (4)
  2. What signs suggest a life-threatening attack? CHEST
  3. When can you discharge a patient after a severe or life threatening attack? (2)
  4. When is ITU admission indicated?
  5. What are the management steps? (4)
  6. What should you do if they don’t improve in 15-30 mins? (4)
A
  1. Unable to complete sentences, PEFR <50%, RR >25 and HR>110
2. SpO2 <92% or PEFR <33% 
Cyanosis/confusion 
Hypotension 
Exhaustion/poor respiratory effort 
Silent chest 
Tachy/bradyarrhythmias
  1. If PEFR >75% or stable on discharge medication for 24hrs
  2. If PaCO2 begins to rise on ABG (suggests exhaustion)
  4. 15L high flow O2
  5. SABA + ipratropium neb
  6. Oral pred or IV hydrocortisone
  7. MgSO4 if life threatening
    • Neb SABA every 15 mins and continue ipratropium
    • MgSO4 IVI over 20 min
    • SABA IVI
    • Consider ITU
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11
Q

Sarcoidosis:

  1. What is sarcoidosis? Who is it most common in?
  2. What are the skin signs of sarcoidosis? (2)
  3. What pulmonary manifestations are seen with sarcoidosis? (3)
  4. Which electrolyte abnormality is seen? Why does it occur? What test should be done after this?
  5. Which other blood test may be raised?
  6. What is the management for acute and chronic sarcoidosis?
  7. What are the indications for steroid therapy? (4)
  8. What are some non-pulmonary manifestations? (4)
A
  1. Multi-system chronic inflammatory granulomatous disorder of unknown origins. 20-40 F Afro-Caribbean
  2. Erythema nodosum + Lupus pernio
  3. Airflow obstruction, restrictive spirometry, BHL on CXR
  4. Hypercalcaemia - macrophages in granulomas increase conversion of Vit D to Ca2+
    24hr urine - hypercalciuria
  5. ESR
  6. Acute = bed rest and NSAIDs
    Chronic = Steroids
    • Parenchymal lung disease
      - uveitis
      - hypercalcaemia
      - neuro/cardio involvement
  8. Arthralgia, uveitis, neuropathies, restrictive cardiomyopathy
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12
Q

Interstitial Lung Disease:

  1. What is it? What is seen on spirometry?
  2. What can cause it? (3)
  3. Which drugs can cause it? BANS ME
  4. What are the causes of upper zone ILD? A PENT
  5. What are the causes of lower zone ILD? STAIR
  6. What is the commonest cause?
A
  1. A group of lung disorders which result in the thickening of supportive tissues between the alveoli - restrictive pattern
  2. Asbestos, hypersensitivity pneumonitis, infection
  3. Bleomycin, Amioderone, Nitrofurantoin, Sulfasalazine and Methotrexate
  4. Aspergillosis, Pneumoconiosis, Extrinsic Allergic Alveolitis (Hypersensitivity Pneumonitis), Negative seroarthropathies, TB
  5. Sarcoidosis, Toxins (BANSME), Asbestosis, Idiopathic pulmonary fibrosis, Rheumatological conditions
  6. Idiopathic pulmonary fibrosis
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13
Q

Idiopathic pulmonary fibrosis:

  1. What are the main complications? (3)
  2. What may you see on blood tests? (3)
  3. Who is it most common in? What are hallmark the features? (4)
  4. What is the diagnostic Ix? What will be seen?
  5. What is the only cure?
A
  1. Increased risk of lung Ca, T2 resp failure, Cor pulmonale
  2. Raised Ig and CRP, ANA +ve
  3. 50-70 y/o M with other autoimmune conditions
    Progressive dyspnoea, bibasal fine insp. creps, dry cough and clubbing
  4. High res CT - ‘ground glass’ developing into honeycomb lung with reduced lung volume
  5. Transplant
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14
Q

Hypersensitivity pneumonitis:

1 .What is it?

  1. Which occupations have higher risk? (3)
  2. What is seen on CXR?
A
  1. Hypersensitivity reaction to inhaled matter resulting in granuloma formation and obliterative bronchiolitis
  2. Birds, mushrooms, malt workers
  3. Honeycomb lung
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15
Q

Obstructive Sleep Apnoea:

  1. What is it?
  2. What are the RFs? (4)
  3. What are the daytime signs? (4) Wha must be done if there is excessive daytime tiredness?
  4. Which test is diagnostic?
  5. How is it managed?
A
  1. Intermittent closure/collapse of the pharyngeal airway during sleep
  2. Obese, smokers, idiopathic pulmonary fibrosis, neuromuscular disorder
  3. Morning headache, irritability, decreased attention and HTN - inform DVLA
  4. Polysomnography
  5. CPAP during sleep
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16
Q

TB:

  1. What is primary TB? What is the method of spread?
  2. What is secondary TB?
  3. Who is at the greatest risk of secondary TB? (4)
  4. What test must be done on suspected TB?
  5. What Ix are done for latent TB?
  6. What Ix are done for active TB?
  7. What is the hallmark histological sign?
  8. What is the initial phase drug treatment? (4) How long is the course?
  9. What is the continuation phase drug treatment? (2)How long is the course?
  10. What are the main SEs of TB drugs? (4)
  11. What will be seen on CXR?
A
  1. Initial infection but maintained by immune system in Ghon focus which heals via fibrosis and remains dormant - via droplet
  2. Immunocomprised states lead to re-emergence of primary infection
  3. DM, steroids, HIV, elderly
  4. HIV
  5. Mantoux test (if -ve with strong suspicion = IFN-gamma)
  6. Sputum MC+S with acid fast bacilli
  7. Caseating granuloma
  8. Rifampacin, Isoniazid, Pyrazinamide and Ethambutol - 8 weeks
  9. Rifampacin and Isoniazid - 16 weeks
  10. Rifampacin: hepatitis
    Isoniazid: hepatitis
    Pyrazinamide: hepatitis
    Ethambutol: Optic neuritis - test vision and colour vision before
  11. CAVITATING lung lesion
17
Q

Pleural Effusion:

  1. How do you differentiate between a transudate and exudate?
  2. What are the causes of transudates? (3)
  3. What are the causes of exudates? (3)
  4. How is it managed? (2)
  5. What is a raised amylase in pleural fluid suggestive of? (2)
  6. What is low glucose in pleural fluid suggestive of? (2)
  7. What are the causes of blood in pleural fluid? (3)
  8. What are the indications for a chest tube? (2)
A
  1. Transudate = <30mg/L protein on pleural tap
    Exudate = >30mg/L protein on pleural tap
  2. HF, hypoalbuminaemia (cirrhosis, nephrotic syndrome) and hypothyroidism
  3. Infection(commonest), inflammation (TB,RA)and malignancy
  4. Can resolve by treating the cause or drainage or pleuradesis for persistent effusion
  5. Pancreatitis or oesophageal perforation
  6. RA or TB
  7. Mesothelioma, PE or TB
  8. Signs of empyema - purulent/turbid/cloudy fluid or pH<7.2
18
Q

What is Churg-Strauss syndrome?

Which Antibody test is positive with Churg-Strauss?

A

A syndrome of three phases:
1. Patients have allergy or asthma which causes inflammation in the nasal passage leading to polyp development

  1. The second phase is eosinophilia

ANCA (anti-neutrophil cytoplasmic antibody)

  1. The third stage is vasculitis which can present as AKI and petechial rash
19
Q

Industrial worker disease:

  1. What are the features of mesothelioma? (4)
  2. What is the diagnostic test of mesothelioma? How is it treated?
  3. Where do mesotheliomas commonly metastasise to? (2)
  4. Which occupation is at greatest risk of pneumoconiosis? Describe the two main types of pneumoconiosis
  5. Which condition can develop ‘pleural plaques’ ?
  6. Asbestosis can increase the risk of which cancers? (2)
A
  1. Dyspnoea, WL, pleuritic chest pain with clubbing
  2. Thoracoscopy - chemotherapy
  3. The contralateral lung and peritoneum
  4. Coal workers
    Simple pneumoconiosis - commonest type and usually asymptomatic but can progress to massive pulmonary fibrosis. Many round upper zone opacities on CXR

Massive pulmonary fibrosis - large round fibrotic masses in the lung in the upper zones. Black sputum, dyspnoea on exertion and cough.

  1. Asbestosis - pleural plaques are non-malignant
  2. Bronchial adenocarcinoma and mesothelioma
20
Q

Asthma Management:

  1. What are the drug Mx steps? (7)
  2. What is the main SE of inhaled ICS?
  3. When would you consider LTRA?
A
  1. SABA PRN
  2. SABA + Low Dose ICS
  3. SABA + Low Dose ICS + LTRA
  4. SABA + Low Dose ICS + LABA (+/- LTRA based on response)
  5. SABA + MART (combi low dose ICS + LABA) +/- LTRA
  6. SABA + MART (med dose ICS) +/- LRTA
  7. SABA + High Dose ICS or LAMA/theophylline
  8. Oral candidiasis
  9. ESP. For exercise or NSAID induced asthma
21
Q

What is the difference between CPAP and BiPAP?

A

BiPAP helps with breathing but also helps by ‘sucking’ away excess CO2 which is better for T2 resp failure (COPD and mechanical resp failure)

CPAP is better in T1 resp failure as it blows air constantly into the patients airway and they need no assistance blowing off CO2.

Respiratory (1 decks)

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