resp Flashcards
1
Q
Features of life threatening asthma?
A
- PEFR <33%
- SpO2 <92%
- Normal pCO2 (4.6-6.0)
- Silent chest, cyanosis, feeble resp effort
- Brady/ hypotension
- exhaustion/ confusion/ coma
2
Q
Features of Severe Asthma?
A
- PEFR 33-50%
- can’t complete sentences
- RR >25
- HR >110
3
Q
Features of Moderate asthma?
A
- PEFR 50-75%
- speech normal
- RR <25
- HR <110
4
Q
Near-fatal asthma?
A
raised pCO2 -> requiring mechanical ventilation
5
Q
CXR in asthma not routinely recommended unless…?
A
- life threatening asthma
- Suspected pneumothorax
- failure to respond to treatment
6
Q
When do BTS guidelines recommend ABG for asthma attacks?
A
oxygen sats <92%
7
Q
Pathophysiology of Alpha-1 antitrypsin deficiency
A
- A1AT protects against enzymes such as neutrophil elastase.
- lack of A1AT (protease inhibitor normally produced by liver) causes emphysema
8
Q
Genetics of Alpha-1 antitrypsin deficiency
A
- auto recessive
- chr 14
9
Q
features of alpha-1 antitrypsin deficiency?
A
- lungs: panacinar emphysema, most marked in lower lobes
- liver: cirrhosis/ HCC in adults, cholestasis in children
10
Q
Ix of Alpha-1 antitrypsin deficiency?
A
- A1AT concentrations
- spirometry - obstructive picture
11
Q
Management of Alpha-1 antitrypsin deficiency?
A
- no smoking
- supportive: bronchodilators, physio
- IV A1AT protein concentrates
- Surgery: lung volume reduction surgery, lung transplant
12
Q
Features of cryptogenic organizing pneumonia?
A
- diffuse interstitial lung disease
- not assoc w smoking
- cough, SOB, fever, malaise
- elevated ESR/ CRP
- Bilateral patch/ ground glass opacities
- TF reduced
13
Q
Treatment of cryptogenic organizing pneumonia?
A
watch and wait if mild, if severe -high dose oral steroids
14
Q
most common organism isolated from patients with bronchiectasis?
A
haemophilus influenzae
15
Q
Management of bronchiectasis: what is most important for long term control of symptoms?
A
inspiratory muscle training + postural drainage
16
Q
Bronchoscopy showing “cherry red ball”
A
Lung Carcinoid
17
Q
features of lung carcinoid?
A
- typical age 40-50y
- smoking not assoc
- slow growing e.g long hx of cough, recurrent haemoptysis
- often centrally located + not seen on CXR
- cherry red ball often seen on bronchoscopy
18
Q
management of lung carcinoid?
A
surgical resection
19
Q
1st line for moderate or severe obstructive sleep apnoea?
A
CPAP
20
Q
1st line mx of Chlamydia psittaci?
A
doxycycline
21
Q
management of pleural plaques?
A
- nothing, no follow up needed as pleural plaques are benign and do not undergo malignant change
22
Q
asbestosis causes fibrosis in what part of the lung?
A
lower lobe fibrosis
23
Q
Contraindications to lung surgery?
A
- stage IIIb or IV (i.e. metastases present)
- FEV1 < 1.5 litres (general cut off)
- malignant pleural effusion
- tumour near hilum
- vocal cord paralysis
- SVC obstruction
24
Q
Causes of lower zone pulmonary fibrosis?
A
- idiopathic
- most connective tissue disorders e.g. SLE
- drug-induced: amiodarone, bleomycin, methotrexate
- asbestosis
25
Causes of Upper zone pulmonary fibrosis?
CHARTS:
```
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
```
26
management of primary pneumothorax if rim of air >2cm OR SOB?
needle aspiration.
- > if this fails, then chest drain
- > advise STOP smoking!
27
management of secondary pneumothorax if rim >2cm and/or SOB?
- chest drain insertion
28
management of secondary pneumothorax if rim of air is 1-2cm?
aspiration
29
management of secondary pneumothorax if rim of air <1cm?
oxygen + admit for 24h
30
What is KCO (transfer co-efficient of carbon monoxide) and how is it affected in lung disease?
KCO is a measure of the efficiency of gas exchange into the blood stream. It is reduced if the lungs are damaged and increased if there is additional blood in the lungs to remove carbon monoxide.
31
What is TLCO (Transfer factor for carbon monoxide)?
TLCO = KCO x Alveolar volume
- The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion.
32
Causes of raised TLCO (Transfer factor for carbon monoxide)? ie. increased rate of gas diffusion from alveoli into blood
- asthma
- pulmonary haemorrhage (Wegener's, Goodpasture's)
- left-to-right cardiac shunts
- polycythaemia
- hyperkinetic states
- male gender, exercise
33
Causes of reduced TLCO (Transfer factor for carbon monoxide)? ie. reduced rate of gas diffusion from alveoli into blood
- pulmonary fibrosis
- pneumonia
- PE
- pulmonary oedema
- emphysema
- anaemia
- low cardiac output
34
Causes of conditions which increase KCO (increased efficiency of gas exchange) but have a normal/ reduced TLCO (ie. reduced rate of gas diffusion from alveoli into blood- due to reduced alveolar volume) ?
- pneumonectomy/lobectomy
- scoliosis/kyphosis
- neuromuscular weakness
- ankylosis of costovertebral joints e.g. ankylosing spondylitis
35
Features of silicosis?
- upper zone lung fibrosis
| - 'egg-shell' calcification of the hilar lymph nodes
36
MOA of varenicline?
nicotinic receptor partial agonist
37
MOA of bupropion?
a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
38
CI for bupropion?
epilepsy (small risk of seizures), pregnancy, breast feeding, eating disorder
39
Smoking cessation for pregnancy women?
1st line: CBT
| - nicotine replacement therapy
40
Diagnosistic test for obstructive sleep apnoea?
polysomnography (sleep studies)
41
Lofgrens syndrome?
acute form of sarcoidosis characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia
42
Heerfordt's syndrome (uveoparotid fever) ?
parotid enlargement, fever and uveitis secondary to sarcoidosis
43
Ix findings of extrinsic allergic alveolitis?
- imaging: upper/mid-zone fibrosis
- bronchoalveolar lavage: lymphocytosis
- serologic assays for specific IgG antibodies
- blood: NO eosinophilia
44
hypercalcaemia in sarcoidosis?
macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
45
oxygen dissociation curve - shift to left =?
decreased oxygen delivery to tissues
46
oxygen dissociation curve - shift to right =?
increased oxygen delivery to tissues
47
factors causing oxygen dissociation curve to shift left?
- everything that decreases oxygen delivery to tissues
HbF, methaemoglobin, carboxyhaemoglobin
Low [H+] (alkali)
Low pCO2
Low 2,3-DPG
Low temperature
48
factors causing oxygen dissociation curve to shift right?
- causing raised oxygen delivery
Raised [H+] (acidic)
Raised pCO2
Raised 2,3-DPG*
Raised temperature
49
organism implicated in malt workers lung? (part of EAA)
Aspergillus clavatus
50
Organism implicated in farmers lung (part of EAA)?
spores of Saccharopolyspora rectivirgula from wet hay
51
organism implicated in bird fanciers lung (part of EAA)?
avian proteins from bird droppings
52
organism implicated in mushroom workers lung (part of EAA)?
thermophilic actinomycetes
53
paraneoplastic features of small cell lung ca?
- ADH -> Hypona
- ACTH -> Cushings
- Lambert Eaton syndrome
54
paraneoplastic features of squamous cell lung ca?
PTH-related peptide, clubbing, hypertrophic pulmonary osteoarthropathy, ectopic TSH -> Hyperthyroid
55
pleural effusion - pleural fluid showing low glucose assoc w?
rheumatoid arthritis, TB
56
pleural effusion - pleural fluid showing raised amylase assoc w?
pancreatitis, oesophageal perforation
57
pleural effusion - pleural fluid showing heavy blood staining assoc w?
mesothelioma, Pulmonary embolism, TB
58
Genetics of Cystic fibrosis?
Chr 7, auto recessive, CFTR gene
59
catamenial pneumothorax
cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax
60
Paraneoplastic features of lung adenocarcinoma?
gynaecomastia, Hypertrophic pulmonary osteoarthropathy
61
1st line management of COPD?
SABA/ SAMA
62
what features do NICE suggest to determine whether pt with suspected COPD has asthmatic/ steroid responsive features?
- any previous diagnosis of asthma/ atopy
- High eosinophil count in FBC
- Peak flow: substantial diurnal variation in PEF (>/= 20%)
- substantial variation in FEV1 over time (>400mL)
63
management of COPD if no asthmatic features?
- add LABA/ LAMA
| - if on SAMA, discontinue and switch to SABA
64
management of COPD if asthmatic features?
- LABA + ICS
- then Triple therapy ie. LAMA + LABA + ICS
- if on SAMA, discontinue and switch to SABA
65
what investigations to do before starting oral prophylactic antibiotic therapy in COPD?
- stop smoking
- CT thorax to exclude bronchiectasis
- sputum culture to exclude atypical infections/ TB
- LFTs + ECG to exclude QT prolongation as azithromycin can prolong QT
66
features of Loffler's syndrome
- thought to be due to parasites such as ascaris lumbricoides causing an alveolar reaction
- transient CXR shadowing and blood eosinophilia
- fever, cough, night sweats
- generally self limiting, <2 weeks
67
mx of allergic bronchopulmonary aspergillosis
oral steroids.
| 2nd line - itraconazole
68
Contraindications for varenicline?
pregnancy/ breast feeding.
| caution- depression/ self harm
69
features of Churg Strauss / eosinophilic granulomatosis with polyangiitis?
asthma, blood eosinophilia, paranasal sinusitis, mono neuritis multiplex, pANCA +
70
what drug class might precipitate Churg Strauss?
Leukotriene receptor antagonists
71
genotype of homozygous A1AT deficiency leading to 50% and 10% normal A1AT levels?
50% of normal: piSS
10% of normal: PiZZ
Normal: PiMM
72
features of Kartagener's?
- dextrocardia/ situs inversus
- bronchiectasis
- recurrent sinusitis
- sub fertility
73
most common chemical causing occupational asthma?
isocyanates
- example occupations include spray painting and foam moulding using adhesives
74
Investigation of choice for assessing compression of upper airway?
Flow volume loop
75
factors associated with poor prognosis in sarcoidosis?
- insidious onset, symptoms > 6 months
- absence of erythema nodosum
- extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
- CXR: stage III-IV features
- black people
76
prophylaxis medication to prevent acute mountain sickness?
acetazolamide (a carbonic anhydrase inhibitor)
77
Management of high altitude cerebral oedema?
descent, dexamethasone
78
Management of high altitude pulmonary oedema?
descent, oxygen if avail.
- nifedipine, dexamethasone, acetazoleamide, phosphodiesterase type V inhibitor* (all work by reducing systolic pulmonary artery pressure)
79
what is a specific Cystic fibrosis contraindication to lung transplantation?
chronic infection with Bulrkholderia cepacia
80
Diet advice in Cystic fibrosis?
High calorie, high fat with pancreatic enzyme supplementation with every meal
81
Lumacaftor/ Ivacaftor?
- used to treat Cystic fibrosis
- lumacaftor increases the number of CFTR proteins transported to cell surface
- ivacaftor is a potentiator of CFTR, increasing the probability that the defective channel will be open
82
Indication for steroid treatment in Sarcoidosis?
- patients with chest x-ray stage 2 or 3 disease + symptomatic.
- hypercalcaemia
- eye, heart or neuro involvement
83
CXR findings in idiopathic pulmonary fibrosis?
bilateral interstitial shadowing (typically small, irregular, peripheral opacities - 'ground-glass' -> later progressing to 'honeycombing')
84
CXR stages in Sarcoidosis?
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
85
How does silica lead to TB?
Silica is a Risk factor for developing TB as silica is toxic to macrophages
86
what type of lung cancer would be most likely to cavitate?
squamous cell lung ca
87
causes of bilateral hilarity lymphadenopathy?
sarcoidosis, TB.
- lymphoma/other malignancy
- pneumoconiosis e.g. berylliosis
- fungi e.g. histoplasmosis, coccidioidomycosis
88
which COPD patients should be assessed for long term oxygen therapy?
- very severe airflow obstruction (FEV1 < 30% predicted). - - consider if FEV1 30-49%
- cyanosis
- polycythaemia
- peripheral oedema
- raised JVP
- oxygen saturations = 92% RA
89
when to offer LTOT to COPD patients?
Offer LTOT to patients with pO2 of < 7.3 kPa on 2 ABGs
OR
pO2 of 7.3 - 8 kPa + one of:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
90
diagnosis of asthma in adults?
FeNO test and spirometry with reversibility
91
management of very early stage (T1-2a, N0, M0) small cell lung ca?
referral for surgery
92
Which type of hypersensitivity reaction predominates in the acute phase of extrinsic allergic alveolitis?
type III
93
what is re-expansion pulmonary oedema?
a complication that can develop following over rapid aspiration / drainage of pneumothorax/effusion -> can lead to over-rapid re-expansion of the lung + oedema
94
Risk factors for re-expansion pulmonary oedema?
1. Longer duration of lung collapse
2. Larger volume of lung collapse
3. Rapid drainage of pleural fluid/air
4. Application of negative pleural pressure (suction)
5. Younger age of patient
95
Calcification in lung metastases are usually seen in which type of tumours?
chondrosarcoma/ osteosarcoma
96
most common organism isolated from patients with bronchiectasis?
haemophilus influenzae
97
HLA association for bronchiectasis?
HLA DR1
98
approximate normal anatomical dead space in healthy adult?
approx 150ml
99
patients on LTOT, what is the minimum length of time they should be on oxygen daily?
15 h/ day
preferably up to 18h/day
100
What demonstrates eosinophilic inflammation in asthmatics?
One or more of:
- sputum eosinophils >/= 3%
- FENO: 50 ppb or >
- Eosinophil count 0.3 x 10^9/L or >
- prompt deterioration of asthma vontrol after a 25% or less reduction in inhaled corticosteroid dose
101
Management of inadequately controlled eosinophilic asthma? Already on steroids
Anti IL5 therapy ie. Mepolizumab
* particularly useful in patients on long term steroid therapy
* * can improve asthma to such an extent that may be able to cease oral steroids
102
What is considered low/ moderate/ high dose Inhaled corticosteroids in adults?
<= 400 mcg budesonide low
400-800 moderate
>800 high
103
Follow up for lung nodule <5 mm, or clear benign features, or unsuitable for treatment?
Can be discharged
104
Follow up for lung nodule 5-6mm, or =>8mm and low risk of malignancy using Brock model?
CT thorax in 1 year if 5-6mm, or in 3 months if >=6mm
105
Follow up of Lung nodule >= 8mm and high risk of malignancy using brock model?
CT-PET
+/- biopsy if CT PET shows high uptake
106
What are some predictors of lung cancer in the Brock model?
```
older age
female sex
family history of lung cancer
emphysema
larger size
upper lobe nodule location
part-solid nodule type
lower nodule count
spiculation
```
107
Most common bacterial organisms causing COPD infective exacerbations?
1. haemophilus influenzae
- streptococcus pneumoniae
- moraxella cararrhalis
108
What are some drugs that cause pleural effusion as side effects?
Nitrofurantoin
Methotrexate
Amiodarone
109
Respiratory follow up if pt on long term nitrofurantoin?
Spirometry every 3-6 months
- acute: consolidation
- chronic: fibrosis, effusions
110
Non respi causes of exudative pleural effusion?
```
Connective tissue disease: RA, SLE
Malignancy
Pancreatitis
dresslers syndrome (2’ pericarditis)
Yellow nail syndrome: yellow nails, 1’ lymphoedema, respi problems
```
111
Risk factor for MERS coronavirus
Contact with camels including camel products such as milk
112
What medication can you give to anxious patient on NIV to calm them?
Haloperidol or morphine
113
Definition of pulmonay hypertension?
Sustained elevation in mean pulmonary arterial pressure of > 25 mmHg at rest
114
What causes increased DLCO? (Diffusing capacity of the lung for CO)
Pulmonary haemorrhage
Polycythaemia
L-> R carduac shunting
115
Management of secondary pneumothorax If >50yo + rim of air >2cm +/- SOB
chest drain
116
Management of secondary pneumothorax if <1cm?
Give oxygen and admit for 24h
117
Management of secondary pneumothorax if rim of air is between 1-2cm?
Aspiration.
If fails-> for chest drain
Admit for 24h
118
Pneumothorax + airplane rules?
Civil aviation authority: 2 weeks after CXR shows resolution
British thoracic society: 1 week post CXR check
119
Diving and pneumothorax?
Should be permanently avoided unless pt has undergone bilateral surgical pleurectony and has normal lung function and chest CT post op
120
Bubbling of chest drain continuously after chest drain inserted to drain empyema?
Suggestive of bronchopleural fistula
121
Relative contraindications to chest drain insertion?
INR > 1.3
Plt <75
Pulmonary bullar
Pleural adhesions
122
Management of re-expansion pulmonary oedema following chest drain insertion?
- clamp chest drain
| - urgent CXR
123
How to reduce risk of reexpansion pulmonary oedema following chest drain insertion?
Drain tubing should be clamped regularly in the event of rapid fluid output
(Ie. Max 1L every 6h)
124
When to remove chest drain of pleural effusion?
No output >24h + imaging shows resolution of fluid collection
125
When to remove chest drain for pneumothorax?
When no longer bubbling spontaneously/ when coughing and ideally when imaging shows resolution of pneumothorax
126
Renal manifestation of granulomatosis with polyangiitis?
Rapidly progressive GN
| “Pauci immune”, 80% of pts
127
Investigations in wegeners (GPA)?
cANCA + in > 90%
pANCA + in 25%
CXR: possibly cavitating lesions
128
Renal biopsy findings in wegeners granulomatosis?
Epithelial crescents in Bowman’s capsule
129
Management of wegeners granulomatosis?
Steroids
Cyclophosphamide (90% response)
Plasma exchange
Median survival 8-9 yrs
130
Silicosis and TB?
Patients with silicosis are at higher risk of tuberculosis infection that is more severe and extensive than for other people = silicotuberculosis.
(silica is toxic to macrophages).
131
which subtype of COPD has normal DLCO (Carbon monoxide diffusing capacity)
chronic bronchitis
132
Ix for mesothelioma?
suspicion is normally raised by a chest x-ray showing either a pleural effusion or pleural thickening
->
the next step is normally a pleural CT
133
diagnosis of mesothelioma?
cytology from pleural effusion
.
local anaesthetic thoracoscopy: high diagnostic yield in cytology negative exudative effusions
.
if an area of pleural nodularity is seen on CT -> image-guided pleural biopsy
134
protein level of exudative pleural effusions?
protein >30g/L
135
further ix in exudative pleural effusions?
contrast CT to investigate underlying cause
136
Further management if persistent air leak or failure of lung to reexpand after draining a pneumothorax for 3-5 days?
seek a thoracic surgical opinion
| as may need pleurectomy/ blebectomy/ pleurodesis
136
management of cystic fibrosis patients who are homozygous for delta F508 mutation?
Lumacaftor/Ivacaftor (Orkambi)
- lumacaftor increases no. of CFTR proteins transported to cell surface
- Ivacaftor is a potentiator of CFTR
137
contraindication to CF patients getting lung transplant?
chronic infection with Burkholderia cepacia
138
Medication for symptomatic SOB in end stage COPD unresponsive to other medical tx?
1st line Opioids
| - ie. short acting liquid morphine sulphate prn
139
Eradication of pseudomonas aureginosa in CF patients?
IV anti-pseudomonal antibiotic plus inhaled aminoglycoside for 14 days (e.g IV Ceftazadime + Nebulised tobramycin)
OR
A prolonged course of oral Ciprofloxacin (e.g. 6 weeks)
140
Next step of Diagnosis and staging of a lung mass with lymph node involvement (shown on scans)?
EBUS (endobronchial US) guided mediastinal LN sampling
| -> aids in diagnosis and staging
141
management of tropical pulmonary eosinophilia?
Diethylcarbamazine
142
Causes of tropical pulmonary eosinophilia?
roundworms - Wucheria bancrofti, Brugia malayi
| - spread by mosquitoes
143
features of tropical pulmonary eosinophilia?
- common in Asian subcontinent and Africa
- nocturnal cough, wheeze and SOB
- diagnosis aided by clinical response to diethylcarbamazine (the main tx)
144
most likely causative organism in Loefflers syndrome (eosinophilic pneumonia)?
Ascaris lumbricoides (roundworm)
145
Management of Loeffler's syndrome (eosinophilic pneumonia)?
generally self limiting
| - tx with mebendazole for 3 days might help
146
Flash pulmonary oedema after ACEi initiation?
Renal artery stenosis
| -> ix with MRA
147
Tx of choice for allergic bronchopulmonary aspergillosis?
oral steroids
148
most common lung cancer in adolescents?
bronchial carcinoid
- often presents with recurrent pneumonia
- assoc w smoking
149
1st line management of DM in CF patients?
insulin + high calorie diet
150
what management is available for those with allergic asthma and elevated IgE levels not controlled with normal therapies?
Anti-IgE therapy: Omalizumab
| -> s/c monoclonal antibody that binds to free IgE and prevents activation of mast cells by the antigen
150
what medication is indicated in idiopathic pulmonary fibrosis?
pirfenidone (antifibrotic agent)
| - may be useful in selected patients
151
Recommended threshold of FEV1 for pneumonectomy to be offered to lung cancer patients?
>2L/s
152
recommended threshold for lobectomy for lung cancer patients?
>1.5L/s
153
What management is advised prior to surgery if surgery is indicated in Non small cell lung cancer?
Mediastinoscopy
| - as CT does not always show LN involvement
154
Contraindications to surgery in lung cancer?
```
Stage IIIb or IV (mets present)
FEV1 <1.5L
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVCO
```
155
what is the TLCO cut off for surgery to be recommended in lung cancer?
TLCO recommended to be >40% prior to resective surgery
156
what ventilation decreases overall mortality of ARDS?
maintaining low tidal volume ventilation
157
When to offer LTOT to COPD patients based on ABG results?
1. if pO2 <7.3 on 2 separate ABGs 3/52 apart
| 2. pO2 7.3 -8 kPa with 2' polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulm HTN
157
features of eosinphilic GPA (Churg strauss)
ANCA assoc- small-medium vessel vasculitis
- asthma
- eosinophilia
- sinusitis
- mononeuritis multiplex
- pANCA+
158
Restrictive lung disease
| - Low DLCO but HIGH KCO?
Low Diffusion capacity (DLCO), high rate of CO uptake (KCO)
- > extra pulmonary cause of restrictive lung disease
e. g. obesity
159
lung cancer + intermittent aching and swelling in the wrists and ankles
hypertrophic pulmonary osteoarthropathy
160
rheumatoid arthritis + melanoptysis (coughing up of black sputum) ?
Coal workers pneumoconiosis
| -> severe progressive fibrosis with massive fibrotic nodules (Caplans syndrome)
161
what may you see on CXR/ HRCT in non tuberculous mycobacterial lung infection?
Chest X-ray or HRCT demonstrating cavities, bronchiectasis +/- nodules
161
diagnosis of pulmonary hypertension secondary to chronic thromboembolic disease?
right heart catheterization
| to assess pulmonary pressures
162
indication for nocturnal BIPAP along with LTOT in COPD patients?
if pt develops respiratory acidosis +/- rise in PaCO2 of >1kPa during LTOT assessment
163
Pneumonia + splenomegaly + diarrhoea + epistaxis
Psittacosis
| - chlamydia psittaci
164
features of combined pulmonary fibrosis and emphysema?
SOBOE, UL emphysema and LL fibrosis
- preserved lung volume
- severely reduced capacity of gas exchange
165
Low glucose in pleural fluid sample?
Rheumatoid arthritis
TB
If coupled with likely malignancy: bronchial carcinoma
166
Omalizumab =?
Anti igE monoclonal antibody
| - used in severe allergic asthma
167
Long term management for COPD patients with >/=2 exacerbations despite triple therapy (LABA, LAMA + ICS) + FEV1<50%?
Add roflumilast
| - long acting imhibitor of phosphodiesterase-4 enzyme
168
Nintedanib used in?
Idiopathic pulmonary fibrosis
- small molecule tyrosine kinase inhibitor including the receptors PDGFR (platelet derived growth factor) and FGFR 1-3 (fibroblast derived growth factor) and VEGFR 1-3
169
What to monitor with aminophylline loading?
Cardiac monitoring
| - aminophylline can induce tachyarrhythmias
170
Aminophylline infusion: what blood tests Should be monitored?
RP: hypoK
| LFTs
171
US for pleural effusion aspiration - what indicates likelihood of failure?
Septation density on US
| - indicates various pockets so even if u drain one you might not drain all the effusion
172
Lower zone pulmonary fibrosis causes?
Idiopathic
Connective tissue disorders: e.g. SLE
Drugs: amiodarone, bleomycin, methotrexate
Asbestosis
173
Upper zone pulmonary fibrosis causes?
CHARTS
```
C- coal workers pneumoconiosis
H- Histiocytosis/ hypersensitivity pneumonitis (EAA)
A- ankylosing spondylitis
R- radiation
T- TB
S- silicosis/ sarcoidosis
```
174
Ix in microscopic polyangiitis?
pANCA (against MPO) - positive in 50-75%
| cANCA (against PR3) - positive in 40%
175
What is the benefit of oxygen In the treatment of a pneumothorax?
exchange of nitrogen for oxygen allowing quicker resorption of the pneumothorax
176
Recommended treatment in small cell lung cancer Early stage (T1-2a,N0,M0)?
Surgery
177
Recommended treatment in small cell lung cancer with spread to nodes?
Early stage (T1-2a,N0,M0)-Limited disease (T1-4,N0-3,M0)
4-6 cycles cisplatin based chemotherapy
carboplatin if poor renal function/poor performance status +/- radiotherapy
178
Recommended treatment in small cell lung cancer?
Extensive disease (T1-4, N0-3, M1a/b)
6 cycles platinum based combination chemotherapy + thoracic radiotherapy if good response
179
Average life expectancy of idiopathic pulmonary fibrosis?
3-4 years
180
Appropriate treatment of Pseudomonas positive bronchiectasis failing to respond to oral ciprofloxacin ?
Change to IV tazocin, ceftazidime, aztreonam or meropenem
181
Appropriate treatment of Pseudomonas positive bronchiectasis failing to respond to oral ciprofloxacin ?
Change to IV tazocin, ceftazidime, aztreonam or meropenem
182
What investigation would aid in distinguishing chylothorax from pseudochylothorax?
chylothorax is high in triglycerides and chylomicrons
pseudochylothorax would be high in cholesterol.
183
Chylothorax?
Chylothorax = the accumulation of lymph in the pleural space. This can occur following damage to the thoracic duct in surgery or in malignant melanoma.
184
Pseudochylothorax?
A pseudochylothorax occurs with longstanding fibrotic pleura.
- milky white fluid, high in cholesterol
185
What is Lymphangioleiomyomatosis?
affects premenopausal women causing proliferation of atypical smooth muscle cells in the lungs, lymphatics and uterus, most likely caused by oestrogens
186
What is associated with Lymphangioleiomyomatosis?
tuberous sclerosis, renal angiomyolipomas.
187
Presentation of Lymphangioleiomyomatosis?
SOB due to progressive ILD, pneumothorax or chylous pleural effusion
Lung damage is similar to emphysema with:
- reduced FVC, TLCO and KCO
- increased TLC.
188
Management / medication to delay disease progression in lymphangioleiomyomatosis?
Medroxyprogesterone
| - anti-oestrogen used to delay disease progression.
189
Chest x-ray shows bat wings + diagnosis confirmed with bronchoalveolar lavage (milky fluid, PAS positive material).
Alveolar proteinosis
- accumulation of lipoproteinaceous material in alveolar spaces
- most commonly affects males
- can be 2’ insecticides, silica, HIV
190
oculocutaneous albinism, abnormal platelet function and interstitial lung disease
Hermansky Pudlak syndrome
191
Chest x-ray shows bat wings + diagnosis confirmed with bronchoalveolar lavage (milky fluid, PAS positive material).
Alveolar proteinosis
- accumulation of lipoproteinaceous material in the alveolar spaces
* most commonly affects males
* can be 2’ to insecticides, silica, HIV.
192
Apical lung fibrosis
+
Work in aerospace industry
Or
manufacture of fluorescent light bulbs/golf-club heads
Berylliosis
- caused by inhalation of the fumes of molten beryllium
- causes lung fibrosis + BL hilar lymphadenopathy
193
What is the most useful pleural fluid marker to make a diagnosis of a haemothorax?
Haematocrit
-If the Hct of the pleural fluid is >
1/2 of peripheral blood Hct, the patient has a haemothorax.
194
What test is most useful in determining prognosis of idiopathic pulmonary fibrosis?
impaired gas exchange: reduced transfer factor (TLCO)
195
Management of theophylline poisoning?
* consider gastric lavage if <1 hour prior to ingestion
* activated charcoal
* whole-bowel irrigation can be performed if theophylline is sustained release form
* charcoal haemoperfusion is preferable to haemodialysis
196
Emphysema pts: who are likely unsuitable candidates for lung volume reduction surgery?
1. non-upper lobe emphysema + high exercise capacity.
| 2. FEV1<20% + homogenous distribution of emphysema OR TLCO < 20%
197
Treatment of histoplasmosis?
amphotericin or itraconazole
198
Ferritin target for CKD patients on ferrous fumarate replacement?
~500
should be below <800
199
Hyperventilation syndrome: what questionnaire can you use?
Nijmegen questionnaire
| - score of >23/64 is diagnostic of HVS
200
Aetiology of Group I pulmonary Hypertension?
A for Pulmonary Arterial Hypertension
201
Causes of Group i pulmonary hypertension?
- idiopathic*
- familial
- associated conditions: collagen vascular disease, congenital heart disease with systemic to pulmonary shunts, HIV**, drugs and toxins, sickle cell disease
- persistent pulmonary hypertension of the newborn
202
Aetiology of group 2 pulmonary hypertension?
pulmonary hypertension secondary to left heart disease
B for BARDIAC
203
Causes of Group 2: Pulmonary hypertension with left heart disease?
- left-sided atrial, ventricular or valvular disease such as LV systolic/ diastolic dysfunction, mitral stenosis and mitral regurgitation
204
Aetiology of group 3 pulmonary hypertension?
pulmonary hypertension secondary to lung disease
C for Chronic Lung stuff
205
Causes of Group 3: Pulmonary hypertension secondary to lung disease/hypoxia?
- COPD
- interstitial lung disease
- sleep apnoea
- high altitude
206
Aetiology of group 4 pulmonary hypertension?
IV pulmonary hypertension secondary to chronic thromboembolic disease
D for D DIMER HIGH
207
Aetiology of group 5 pulmonary hypertension?
V pulmonary hypertension with unclear causes
E for everything else (basically unsure)
208
Causes of group V pulmonary hypertension?
Miscellaneous conditions
| - lymphangiomatosis e.g. secondary to carcinomatosis or sarcoidosis
209
Features of histoplasmosis?
Due to the fungus Histoplasma capsulatum
- URTI
- retrosternal pain
210
What medication may be indicated in COPD patients still symptomatic on triple therapy with LABA ICS/LAMA/SABA?
Roflumilast
- phosphodiesterase inhibitor
If:
1. FEV1 after bronchodilator <50%
AND
2. 2 or more exacerbations in the previous 12 months
211
Occupational risk factors for berylliosis?
- inhalation of fumes of molten beryllium
> aerospace industry
> manufacture of fluorescent light bulbs/ golf club heads
212
Most useful pleural fluid marker to diagnoses haemothorax?
Haematocrit
| > if Hct is more than half of pts peripheral blood Hct, the pt has haemothorax
213
Management of non small cell lung ca if not for surgery
Radiotherapy
- response to chemo is poor
214
What is the primary form of treatment for ARDS?
invasive mechanical ventilation with low tidal volumes*
+ high positive end-expiratory pressures
*low tidal vol avoids alveolar hyperinflation
