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Flashcards in Resp Deck (373):
1

What results after exposure to antigen in sensitised individual during anaphylactic shock

Histamine release ~> capillary leak, oedema, wheeze, cyanosis

2

List the steps in treating a patient with anaphylaxis

- remove trigger
- maintain airway and intimate if necessary
- 100% O2
- IM adrenaline 0.5mg
- IV hydrocortisone 200mg
- IV chlorpheniramine 10mg
- fluid resusc if hypotension
- NEB salbutamol
- NEB adrenaline

3

List the drugs given IM or IV in anaphylactic shock, and their doses

- IM adrenaline
- IV hydrocortisone
- IV chlorpheniramine

4

What NEBs would you give in anaphylaxis

Salbutamol
Adrenaline

5

Define mild asthma

Pefr > 75%

6

Define moderate asthma

Pefr 50-75%

7

Define severe asthma

- Pefr 33-50% of best or predicted
- cannot complete sentences
- resp rate > 25/min
- hr > 110/min

8

Define life threatening asthma

- Pefr less than 33%
- sats less than 92% or po2 less than 8kpa
- silent chest
- exhaustion, confusion
- normal pco2

9

Define near fatal asthma

Raised paco2 (co2 retention)

10

What are the steps for managing acute asthma exacerbation

- ABCDE
- O2 as needed
- nebulised salbutamol 5mg
- oral prednisolone 40mg / IV hydrocortisone if po not possible

11

How do you manage sever asthma

Nebulised ipratropium bromide 500mcg
Salbutamol back to back may be needed

12

How do you manage life threatening or near fatal asthma

- urgent itu/anaesthetist assessment
- urgent portable CXR
- IV aminophylline
- IV salbutamol if nebulised is ineffective

13

What is the mechanism of action of ipratropium bromide

Anticholinergic - blocks M3 receptors

14

What so2 would you aim for in a patient with COPD

88-92%

15

How do you manage COPD exacerbations

Oxygen via Venturi mask
NEBs - salbutamol, ipratropium
Prednisolone 30mg od 7/7
Abx if infection indicated
CXR
Consider niv/itu

16

When would you consider niv in a patient with exacerbation of COPD

Type 2 resp failure and ph 7.25-7.35

17

When would you consider itu referral in a patient with COPD exacerbation

Ph less than 7.25

18

What are the features on investigation and CXR that would indicate pneumonia

- consolidation on CXR
- fever
- purulent sputum
- raised wcc
- raised CRP

19

Define anaphylaxis

A type 1 ige-mediated hypersensitivity reaction

20

What are the parts that make up the CURB65 score

C - confusion, mmt 2 or more points worse
U - urea >7.0
R - Resp rate > and including 30/min
B - BP less than 90 systolic or 60 diastolic
65 yo or older

21

What does the CURB65 score predict

Mortality in community acquired pneumonia

22

How should a patient with a curb65 of 0-1 be treated

As outpatient

23

How should patient with curb65 of 2 be treated

Consider short hospital stay

24

How should a patient with curb65 of 3-5 be treated

Hospitalisation + consider if they need itu

25

What are the two ways to define a massive haemoptysis

- >240mls in 24 hours
- >100mls/day over consecutive days

26

How is massive haemoptysis managed

ABCDE
- lie patient on side of suspected lesion
- oral tranexamic acid
- stop NSAIDs/aspirin/anticoagulants
- abx if suspected RTI
- consider vit k

27

How would you investigate someone with massive haemoptysis

Ct aortogram

28

How does tranexamic acid work?

Inhibits breakdown of fibrin by inhibiting plasminogen being converted to plasmin (plasmin acts to cause fibrin degradation)

29

What features would you see on an X-ray of a patient with tension pneumothorax

- lung is blacker on side of tension pneumothorax
- mediastinum shifted into contralateral hemithorax
- trachea deviated away from side of pneumothorax
- kinking and compressing of great veins

30

What may be found on examination of patient with tension pneumothorax

- increased percussion note (hyper resonance)
- reduced air entry
- reduced breath sounds
...on affected side

31

What is the management of tension pneumothorax

- large bore iv cannula into 2nd intercostal space in mid clavicular line
- chest drain into affected side

32

List some of the symptoms and signs of PE

- sudden onset pleuritic chest pain
- pleural rub
- sob
- haemoptysis
- syncope
- hypotension
- tachypnoea
- cyanosis

33

At what O2 sats would you perform abg

Less than92%

34

What are the major risk factors for PE

- surgery
- obstetric causes
- lower limb #
- varicose veins
- malignancy
- reduced mobility
- previous proven vte

35

Give a couple of surgical procedures that are major risk factors of PE

Abdo/ pelvic
Knee or hip replacement

36

Give the steps for managing PE

ABCDE
- O2
- fluids
- thrombolysis if massive PE confirmed
- full anticoagulation

37

What would you thrombolyse with in massive PE

Iv alteplase

38

What defines massive PE

Hypotension/imminent cardiac arrest

39

List some of the relative factors which act to contraindicate thrombolysis

Warfarin
Pregnancy
Advanced liver disease
Infective endocarditis

40

What may an ecg show with PE

Sinus tachycardia
Right axis deviation
Rbbb
Af

41

What may be seen on CXR with a PE

- Small pleural effusion
- Wedge shaped area of infarction

42

What may ABGs show in a patient with PE

Pao2 reduced
Paco2 reduced
Often acidosis
(Hypervenitaltion and decreased gas exchange)

43

What is a d diner blood test helpful in diagnosing

PE

44

What towns investigations apart from ecg and CXR may you perform in a patient with suspected PE

CT pulmonary angiogram
V/Q scan

45

Give some of the preventative measures for PE

- TED stockings
- LMWH
- avoid contraceptive pill
- anticoagulation

46

At what blood pressure would you start to consider massive PE

Less than 90mmhg systolic

47

What conditions is asthma often associated with in patients

- eczema
- hay fever
- allergies
- (significant portion also have acid reflux)

48

Give some of the signs of asthma on inspection

- tachypnoea
- audible wheeze
- hyper inflated chest

49

What may you find when examining the chest of a patient with asthma

- hyper resonant percussion
- diminished air entry
- widespread
- polyphonic wheeze

50

What is asthma

A chronic inflammatory disease of the airways, where obstruction is reversible

51

Describe the diurnal variation of asthma

Marked morning dipping of peak flow can predispose to attack

52

Give the two main differentials for wheeze

Acute asthma exacerbation
Bronchitis (inc COPD)

53

What is churg Strauss syndrome

autoimmune condition causing vasculitis, occurs in patients with a history of airway hypersensitivity

54

What is wegeners granulomatosis

Form of vasculitis that can cause damage to the lung and kidneys

55

What is the pathophysiology of asthma

- airway epithelial damage
- inflammatory reaction - mast cells, eosinophils, T cells
- increased numbers of goblet cells
- cytokines amplify inflamm
- mucus plugging if severe

56

What are the features of airway epithelial damage in asthma

- BM thickening
- Sub epithelial fibrosis

57

What are some of the inflammatory mediators involved in asthma pathophysiology

- histamine
- leukotrienes
- prostaglandins

58

What is the criteria that make a patient suitable for discharge following exacerbation of asthma

- pefr >75%
- not needed nebulised inhalers for at least 24hours

59

What steps would be take to manage a patient after discharge following presentation with acute asthma exacerbation

- 5 days oral prednisolone
- provide pefr meter
- written asthma action plan
- gp follow up 2 working days
- Resp clinic follow up within 4 weeks

60

What is eosinophilia

Increased eosinophil count in response to allergens, drugs etc

61

List the trigger factors for asthma

- smoking
- urti
- allergens
- exercise/cold air
- occupational irritants
- drugs
- foods/drinks
- stress

62

How may aminophylline/theophylline be useful in treating asthma

Given as prophylaxis at night to prevent morning dip

63

What are some of the side effects of b2 agonists

- tachy
- reduced K+
- tremor
- anxiety

64

Why may LABAs be useful in treating asthma

Can help nocturnal symptoms and reduce morning dips

65

Why should a patient rinse their mouth after using inhaled steroids

Prevent oral candidiasis

66

How may you distinguish whether there is an occupational explore which brings on asthma attacks

Ask patient if they get less/no symptoms over the weekend or during holidays; ask them to measure their peak flow during work and home

67

What is step 1 of the BTS guidelines for asthma management

Inhaled short acting B2 agonist

68

What is step 2 of the BTS guidelines for asthma management

Add inhaled steroid (appropriate to severity of disease)

69

What is step 3 of the BTS guidelines for asthma management

Add LABA +/- theophylline +/- B2 agonist tablet
- if only some response, increase steroid dose
- if no response, stop LABA and increase steroids

70

What is step 4 of the BTS guidelines for asthma management

Add leukotriene receptor antagonist eg montelukast

71

What is step 5 of the BTS asthma management plan

Daily steroid tablet
Refer for specialist care

72

On a ct scan, if one were to see dark round areas, what do they indicate

Air retention causing bullae

73

When is anti IgE monoclonal antibody treatment indicated in a patient with asthma e.g. Omalizumab

Selected patients with persistent allergic asthma

74

What is the definition of COPD

A condition characterised by irreversible airway obstruction which is usually progressive and predominantly caused by smoking

75

What two conditions is COPD an umbrella term for

Emphysema and bronchitis

76

Define emphysema

Enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls

77

Define bronchitis

Inflammation of airways with cough, sputum production for most days for 3 months of 2 successive years

78

What is the difference between diagnosis of emphysema and bronchitis

Emphysema is defined histologically, bronchitis is defined clinically

79

What are the pathophysiological features of COPD

- mucous gland hyperplasia
- loss of filial function
- emphysema
- chronic inflammation (macrophages and neutrophils)
- fibrosis of small airways

80

List the causes of COPD

Smoking
a1-antitrypsin deficiency
Industrial exposure

81

What fev1 ranges indicate mild, moderate and severe COPD

Mild = 50-80%
Mod = 30-49%
Severe = less than 30%

82

How are patient sight COPD managed

- SMOKING CESSATION
- pulmonary rehab
- bronchodilators
- antimuscaricins
- steroids
- mucolytics
- Ltot if appropriate
- lung volume reduction if appropriate

83

What are the indications for lung vol surgery in patient with COPD

Recurrent pneumothorax
Bullous disease

84

How would you treat mild COPD

Antimuscarinic
Or B2 agonist PRN

85

How is moderate COPD managed pharmacologically

Regular antimuscarinic
Or LABA
+ inhaled corticosteroid e.g. Beclamethasone

86

How is severe COPD treated

LABA
+ inhaled steroid
+ anticholinergic

87

What may ecg and CXR show in a patient with COPD

Ecg : ra and rv hypertrophy
CXR: hyperinflation, flat hemidiaphragm, large central pulmonary arteries, bullae

88

How do you know that a lung is hyper inflated on CXR

More than 6 ribs in the MCL above the diaphragm

89

What are the medical features of pink puffers in COPD

Increased alveolar ventilation
Near normal pao2 with normal or slightly low paco2
Breathless

90

What are the medical features of blue bloaters in COPD

Decreased alveolar ventilation
Pao2 is decreased and paco2 is increased
Cyanosed but not breathless
Rely on hypoxia drive

91

Why do blue bloaters rely on hypoxic drive

Their respiratory centres have a decreased sensitivity to co2

92

What can blue bloaters go on to have

Cor pulmonale

93

What can pink puffers go on to have

Type 1 resp failure

94

Why may Ltot be given in a patient with severe COPD

To prevent renal and cardiac damage from prolonged hypoxia

95

How is Ltot (long term O2 therapy) given

Continuous oxygen therapy for most of the day - at least 16 hours/day for a survival benefit

96

At which po2 levels is Ltot offered in COPD patients

Po2 consistently below 7.3 kpa or below 8kpa with cor pulmonale

97

What are some of the drawbacks of Ltot

Reduced mobility and independence

98

Describe the cycle which pulmonary rehabilitation tries to break in patient with COPD

You feel breathless > avoid activity > do less > muscles weaken > get more breathless > feel depressed > you feel breathless

99

What adverse social effects can the vicious cycle of COPD lead to

Increasing isolation and inactivity, which leads to worsening of symptoms

100

What are some of the complications of COPD

Acute exacerbation
Infections
Polycythaemia
Resp failure
For pulmonale
Cancer
Bullae rupture leading to pneumothorax

101

What are the symptoms of COPD

Cough
Sputum
Wheeze
Dyspnoea

102

What are the signs of COPD

Tachypnoea
Use of accessory muscles
Hyperinflation of chest
Reduced expansion
Increased percussion note
Cyanosis
Quiet breath sounds
Wheeze
Cor pulmonale

103

What types of organism tend to cause hospital acquired pneumonia

- gram negative enterobacteria
- s aureus
- pseudomonas
- klebsiella
- bacteroides
- clostridia

104

Give some conditions that may predispose to aspiration pneumonia

Stroke
Myasthenia gravis
Bulbar palsies
Decreased consciousness
Oesophageal disease eg GORD
Poor dental hygiene

105

List some organisms causing pneumonia in immune improvised patients

- pneumocystis jirovecii/P. Carinii
- fungi
- M. Catarrhalis

106

What are the common organisms causing community acquired pneumonia

- strep pneumoniae
- h influenzae
- mycoplasma pneumoniae
- viruses and flu also

107

What will be seen on CXR of patient with pneumonia

Consolidation
Lobar or multi lobar infiltrates
Cavitation
Pleural effusion

108

What are the differentials for consolidation on CXR

- pneumonia
- TB
- lung ca
- lobar collapse (blockage of bronchi)
- haemorrhage

109

What does a curb 65 score act as a guide for

Risk of mortality for patients with pneumonia

110

What other features, except for a high scoring curb 65 can increase risk of death in a patient with pneumonia

- coexisting disease
- bilateral involvement
- multi lobar involvement
- pao2

111

What investigation should you perform in a febrile patient with pneumonia

Blood cultures

112

In severe cases/high curb 65 score, what investigations would you do

Investigations for atypical causes e.g. Serology and urine legionella antigen test

113

On examination of a patient with pneumonia, what signs may you pick up?

signs of consolidation e.g.
- decreased percussion note
- diminished expansion
- bronchial breathing
- increased Fremitus

114

Give some of the steps of pneumonia follow up

- HIV test
- immunoglobulins
- pneumococcal IgG serotypes
- H influenzae B IgG

115

When would you do a follow up appointment and CXR in a patient with pneumonia

In 6 weeks

116

What factors may cause a non-resolving pneumonia (CHAOS)

Complications
Host immunocompromised
Antibiotic inadequate
Organism resistant
Second diagnosis - not pneumonia

117

List some of the complications of pneumonia

Empyema
Lung abscess
Resp failure
Septicaemia
Pericarditis, myocarditis
Pleural effusion
AF

118

What is the management of pneumonia usually

Amoxicillin + clarithromycin/doxycycline (look at hospital guidelines)

119

What is the treatment for aspiration pneumonia

Cefuroxime + metronidazole

120

What is the treatment for atypical pneumonia

Coamoxiclav or cefuroxime/other cephalosporin
+ clarithromycin
+ flucloxacillin (if S. aureus is indicated)

121

When treating a patient with pneumonia, what are your targets for pao2 and sats

Pao2 > 8kpa
Sats >94%

122

If a patient with penumonai becomes septic, who do you refer them to

ITU

123

What can precipitate hypotension in a patient with pneumonia

Dehydration and sepsis

124

Give a skin feature of TB

Erythema nodosum

125

Give non-chest manifestations of TB

Erythema nodosum, lymphadenopathy, meningitis, frequency, dysuria, pericardial effusion

126

By which route is TB spread to become milliary

Haematogenous

127

What is the characteristic CXR feature of TB

Reticulonodular shadowing, usually in upper zone

128

What is the tuberculin test

TB antigen is injected intradermally,
If it is positive, it indicates immunity
If it is strong positive, it indicates active infection

129

What may cause positive tuberculin test in a patient

Immunity - either previous exposure or BCG vaccination

130

What are some of the infective differential causes of haemoptysis

- pneumonia
- TB
- bronchiactesis
- CF
- cavitation lung lesion (e.g. Fungal)

131

What are some of the haemorrhagic differential causes for haemoptysis

- bronchial artery erosion
- PE
- vasculitis
- coagulopathy

132

List the differential diagnoses for haemoptysis

- infections (TB, pneumonia etc.)
- malignancy
- haemorrhagic
- PE

133

If there is a CXR suggestive of TB, what investigation would you do next

Sputum sample

134

If a patient has active non respiratory TB, which investigations would you choose to cover as much as possible

- sputum sample
- CXR
- pleural fluid
- urine sample
- pus
- csf

135

List some risk factors for TB

- past history of TB
- known history of TB contact
- born in country with high TB incidence
- travel to country with high TB incidence
- immunosuppression

136

What is the histological hallmark of TB

Caseating granuloma

137

How would you test for TB bacterium

Ziel Neelsen testing for acid fast bacilli

138

What are the CXR signs for a patient with TB

- consolidation
- cavitation
- fibrosis
- calcification

139

Should you wait for cultures results if histology and clinical picture is consistent with TB

No

140

If a patient with TB has a productive cough, what samples should you collect

Three sputum cultures for acid fast bacilli and TB culture

141

If you have a patient with suspected TB which has atypical features on examination and CXR, what investigation would you then do

Ct

142

If you are unsure between diagnosis of TB or p euro ka, how would you manage that patient

Which treatment as per pneumonia, while investigation possibility of TB

143

What is the standard therapy for TB

- 4 antibiotics for the first 2 months: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
- then followed by two antibiotics for the next 4 months: Rifampicin and isoniazid

144

Why is weight Important when treating a patient with TB

Dose of anti TB antibiotics depends on weight

145

Why do you need to check visual acuity before giving ethambutol

He drug causes ocular toxicity, so you need to test colour vision and acuity before commencing treatment

146

What is DOT

Directly observed therapy - observing patient staking anti TB meds to help with compliance

147

What drug can you give in conjunction with isoniazid to act as prophylaxis for peripheral neuropathy

Pyridoxine

148

What are the two major side effects of Rifampicin

Hepatitis
Orange /red secretions

149

What is the major side effects of isoniazid

Peripheral neuropathy

150

What is the major side effect of Pyrazinamide

Arthralgia

151

What is the main Side effect of ethambutol

Optic neuritis/retro bulbar neuritis

152

What is the pathophysiology of bronchiactesis

Chronic/recurrent infections of the bronchi + bronchioles leading to permanent dilatation of the airways

153

What is the gold standard diagnostic test for bronchiactesis

High res ct

154

What are some of the infective causes for bronchiactesis

Whooping cough, TB, pneumonia, measles

155

What immune deficiency disorder is associated with bronchiactesis

Hypogammaglobulinaemia

156

List some mucus/clearance disorders that are associated with bronchiactesis

Cf
Primary ciliary dyskinesia
Youngs syndrome
Kartagener syndrome

157

What is the triad of youngs syndrome

Bronchiactesis, sinusitis and reduced fertitility

158

What is the triad of Kartagener syndrome

Bronchiactesis, sinusitis and situs inversus

159

What does youngs syndrome cause

Abnormally viscous mucus --> bronchiactesis

160

What does kartageners syndrome cause

Defect in action of cilia --> bronchiactesis

161

What are some of the obstructive causes of bronchiactesis

Foreign body, tumour, extrinsic lymph node

162

List some of the common organisms of bronchiactesis

H influenzae
Pseudomonas aeuroginosa
Mortadella catarrhalis
Strep pneumoniae
S aureus
Aspergillus

163

How is bronchiactesis managed

Treat underlying cause
Physiotherapy
Bronchodilators are supportive
Pulmonary rehab

164

What are the symptoms of bronchiactesis

Persistent cough
Copious purulent sputum
Intermittent haemoptysis

165

What are the signs o/e of patients with bronchiactesis

Finger clubbing
Coarse insp crepts
Wheeze

166

How would you treat latent TB

3 month prophylaxis of Rifampicin and isoniazid (shorter course can improve compliance)

167

How may you treat a patient with renal impairment differently from other patients if they have TB

Give triple rather than quadruple therapy, omitting either Pyrazinamide or ethambutol, as these are renally excreted

168

What is cystic fibrosis

An autosomal recessive disease leading to mutations in the cftr channel, leading to multisystemic disease characterised by thickened mucus

169

What chromosome is the cftr gene found on

17

170

What are some of the feature in neonates that may alert you that they child has cf

Failure to thrive, meconeum ileus, rectal prolapse

171

How is CF diagnosed

characteristic phenotypic features OR history of sibling CF OR +ve newborn screening test
AND +ve sweat test, genotype +ve, demonstration of abnormal nasal epithelial transport

172

What is a positive sweat test for CF

>60mmol/L Cl-

173

What is the screening for pancreatic exocrine dysfunction I. Patients with cf

Faecal elastase

174

What are the presentations for cf

1) meconeum ileus
2) intestinal malabsorption
3) recurrent chest infections
4) newborn screening

175

What is meconeum ileus

The bowel is blocked by sticky secretions, causing signs of intestinal obstruction

176

What are the symptoms and signs of meconeum ileus

Bilious vomiting, abdo distension, delay in passing meconeum

177

What signs may be seen in a patient's hands if they have cf

Finger clubbing
Cyanosis

178

What features in the urt may a patient with cf have

Chronic sinusitis
Nasal polyps

179

What lrt signs may a patient with cf have

Repeated lrti's
Bronchiactesis
Cough, wheeze,
Pneumothorax
Haemoptysis
Resp failure
Cor pulmonale

180

What GI symptoms may a patient with cf have

- liver disease
- portal hypertension
- gallstones
- pancreatic insufficiency, diabetes
- distal instensti obstruction syndrome
- steatorrhoea

181

What MSK symptoms may be associated with cf

Osteoporosis
Hpoa
Arthritis
Arthropathy

182

What reproductive problems may be found in patients with cf

Male infertility

183

What is the role of the cftr usually and what happens in cf

Usually transports chloride ions outside the cell and into the mucus, and water follows to thin the mucus. In cf this doesn't function normally so the mucus remains thick

184

List some complications of cf

- resp infections
- low body weight
- distal intestinal obstruction syndrome

185

How are resp infections in cf managed

Chest Physio and abx,
Abx may be needed prophylactically to maintain health

186

How may pancreatic insufficiency be managed in cf

Pancreatic enzyme replacement therapy
High calorie intake
Extra supplements
May need NG or PEG feeding

187

How does Distal Intestinal Obstruction Syndrome in CF present usually

Rif mass

188

Why does Distal Intestinal Obstruction Syndrome occur in cf

Intestinal contents in distal ileum and proximal colon are thick and dehydrated, causing obstruction. This is due to insuffiencient pancreatic enzymes

189

Where does faecal obstruction occur in cf patients with Distal Intestinal Obstruction Syndrome

Ileoceacum (unlike constipation, which is whole bowel)

190

What does AXR show in cf patients with DIOS show

Faecal loading at junction of small and large bowel

191

What is some of the lifestyle advice that should be given to patient with cf

- no smoking
- avoid others with infections
- avoid jacuzzis
- clean and dry nebulisers thoroughly
- avoid stables etc
- annual influenza immunisation
- nacl tablets in hot weather

192

List some of the non-lifestyle management techniques for cf

- treat DM if present
- abx
- chest physio
- mucolytics
- bronchodilators
- pancreatic enzyme replacement
- fat soluble vitamin supplements
- urodeoxycholic acid

193

What are the fat soluble supplements

A/d/e/k

194

What bloods would you do on a patient with cf

FBC
U+E
LFT
clotting
Vit a/d/e/k
Annual glucose tolerance test

195

What bacteriological investigations should be carried out in a patient with cf

Cough swab
Sputum culture

196

What may CXR show in a patient with cf when not infected

Hyperinflation
Bronchiactesis

197

What may be the findings on abdo ultrasound in a patient with cf

Fatty liver
Cirrhosis
Chronic pancreatitis

198

What pattern would spirometry show in cf

Obstructive pattern

199

How do you manage advanced cf

- O2
- niv
- lung+/- heart transplant
- diuretics for cor pulmonale

200

What is the pleural cavity

Potential space between the pleural surfaces of the visceral and partietal pleural layers, containing fluid

201

What is the parietal pleura attached to

Chest wall

202

What are pleural plaques

Discrete fibrous areas in the pleura

203

List the types of pneumothorax

- spontaneous - either primary or secondary
- traumatic
-TENSION
- iatrogenic e.g. Post central line insertion

204

What are the risk factors for pneumothorax

- pre existing lung disease
- height
- smoking/cannabis
- diving
- trauma/chest procedure
- Marfans and other connective tissue disorders

205

How is primary pneumothorax over 2cm treated

If symptomatic, give o2 and aspirate

206

What advice would you give to a patient with pneumothorax

No flying or diving until resolved within certain period

207

List the causes of translate effusions

1) hf
2) cirrhosis
3) hypoalbuminaemia
4) PE

208

What is meigs syndrome

Triad of ascites, pleural effusion and benign ovarian tumour

209

How do you treat persistent transudate pleural effusion despite treatment

Aspiration/drainage

210

What defines a pleural effusion as being exudate or transudate

If >30g/l pleural protein, then it's an exudate

211

List the causes of exudate effusion

1) malignancy
2) infections
3) ra and other inflammatory conditions

212

What is lights criteria for pleural effusion used

If the pleural fluid protein is between 25 and 35 g/l, use lights criteria to determine if transudate or exudate

213

What 3 extra factors are used in lights criteria to indicate an exudate rather than transudate

- pleural fluid/serum protein >0.5
- pleural fluid/serum LDH >0.6
- pleural fluid LDH>2/3 of upper limit of normal

214

What is malignant mesothelioma

Tumour of mesothelioma cells, usually in Pleura and associated with asbestos exposure

215

What are the signs and symptoms of mesothelioma

Chest pain
Dyspnoea
Weight loss
Finger clubbing
Recurrent pleural effusion

216

What are the symptoms of spread of mesothelioma

Lymphadenopathy
Hepatomegaly
Bone pain/tenderness
Abdo pain

217

What tests do you perform in a patient with mesothelioma

CXR
Ct
Showing pleural thickening/effusion
Bloody pleural fluid

218

How is mesothelioma treated

Chemo

219

What are the symptoms of pleural effusion

Asymptomatic or dyspnoea, pleuritic chest pain

220

What are the signs on examination of a patient with pleural effusion

- decreased expansion
- stony dull percussion note
- diminished breath sounds
- tactile vocal Fremitus and resonance are decreased
- bronchial breath sounds above effusion

221

What is pluerodesis

Where the pleural space is artificially obliterated with drugs etc

222

What is the definition for ILD

Umbrella term for conditions that affect the lung parenchyma in a diffuse manner

223

What are the pathological features of ild

Fibrosis and remodelling of the interstitium
Hyperplasia of type 2 pneumocytes

224

Which blood investigations should you obtain with ild patients

- ANA
- ENA
- ANCA
- RhF
- anti gbm
- IgG to serum precipitins
- ACE

225

What do positive serum precipitins indicate in ild

Exposure only

226

What is the commonest type of ild

UIP - usual interstitial pneumonia

227

What are the classical findings on examination with a patient with ild

Clubbing, reduced chest expansion, fine inspiratory crepts (Velcro) best heard basally

228

What are some of the signs and symptoms that are shared in conditions that fall under the category of ild

Dyspnoea on exertion
Progressive sob
Non productive dry paroxysmal cough
Abnormal breath sounds

229

What does tlco show in patients with ild

Reduced

230

What imaging investigations would you use for ild

CXR
High res ct

231

In idiopathic pulmonary fibrosis, what is the pathophysiology

Idiopathic interstitial pneumonia, with inflammatory cell infiltrate and pulmonary fibrosis of unknown cause

232

What investigation may be needed for IPF diagnosis

Lung biopsy

233

What are the symptoms of Idiopathic Pulmonary Fibrosis

- dry cough
- exertional dyspnoea
- malaise
- weight loss
- Arthralgia

234

What signs may a patient with IPF have

Cyanosis
Finger clubbing
Fine end inspiratory crepts

235

What are two complications of IPF

Resp failure
Increased chance of lung ca

236

What is the management of IPF (poor prognosis)

Pulmonary rehab
O2
Opiates
Lung transplant

237

Do you give steroids to IPF patients

No

238

Give three respiratory causes of clubbing

- ILD
- lung ca
- bronchiactesis

239

Give some examples of occupations associated with extrinsic allergic alveolitis

1) those in contact with birds
2) farmers
3) mushroom workers
4) sugar workers
5) malt workers
6) coal workers
7) industrial - asbestosis, silicosis

240

What causes extrinsic allergic alveolitis

Inhalation of organic antigen e.g. Fungal spore, to which the individual has been sensitised

241

What are the pahtophysiological changes that occur in patients with extrinsic allergic alveolitis

- alveoli are infiltrated by inflammatory cells

242

What are the pathophysiological changes that occur in chronic phase of extrinsic allergic alveolitis

Granuloma formation and obliterative bronc holistic

243

What is the histological hallmark for sarcoidosis

Non Caseating granulomas

244

What does chest X Ray in a patient with sarcoidosis show

Lots of small nodules

245

What can coal workers pneumoconiosis progress to

Massive fibrosis and eventually cor pulmonale

246

What is ca plans syndrome

Ra
Pneumoconiosis
Pulmonary rheumatic nodules

247

How is ild managed

- remove exposure
- stop smoking
- review drugs that are associated with ild
- transplant
- O2
- palliative

248

What are the three classes of ild

- known cause e.g occupational
- idiopathic
- associated with systemic disorders

249

What are some of the known causes of ild

1) occupational/environmental exposure
2) drugs
3) hypersensitivity reactions

250

What are some of the systemic disorders associated with ild

1) sarcoidosis
2) ra
3) sle, systemic sclerosis, mixed connective tissue disease, sjogrens
4) UC, renal tubular disease, autoimmune thyroid disease

251

List some drugs associated with ild

nitrofuratoin
Bleomycin
Amiodarone
Sulfasalazine

252

List the three idiopathic conditions of ild

1) IPF
2) cryptogenic organising pneumonia
3) lymphocytic interstitial pneumonia

253

What is the definition of obstructive sleep apnoea

Intermittent closure/collapse of the pharyngeal airway, causing aponeic episodes during sleep. Terminated by partial arousal

254

Describe a typical patient with obstructive sleep apnoea

Male, upper body obesity, undersized mandible

255

What is the process that causes obstructive sleep apnoea

EITHER already small pharyngeal size undergoes normal muscle relaxation during sleep and closes airway
OR there is excessive narrowing occurring with relaxation during sleep

256

Give some causes of small pharyngeal size

- fatty infiltration or pharyngeal tissues
- large tonsils
- craniofacial abnormalities
- extra submucosal tissue e.g. Myxeodema

257

Give some physiological causes of excessive narrowing of the airway during sleep (sleep apnoea)

- obesity
- neuromuscular disease
- muscles relaxants e.g. Alcohol, sedatives
- age

258

Why do patients wake up during airway collapse in obstructive sleep apnoea

Arousal deactivates the pahryngeal dilators

259

What are the signs and symptoms of obstructive sleep apnoea

Recurrent arousals during sleep
Poor sleep quality
Daytime somnolence
Sob
Daytime rise in BP
Morning headache

260

What is the name of the scale used to assess daytime sleepiness in patients with obstructve sleep apnoea

Epworth sleepiness scale

261

Give some examples of activities that are assessed when using the epworth sleepiness scale

Reading, watching TV, sitting and talking, resting etc.

262

How are the scores for sleepiness during activities rated in patients with obstructive sleep apnoea

0- would never doze
1- slight chance of dozing
2- moderate chance
3- high chance

263

What are the sleep study options for investigating patients with obstructive sleep apnoea

- overnight oximetry to pick up fluctuations
- limited sleep study
- full polysomnography

264

What does a limited sleep study investigate for patients with sleep apnoea

- overnight oximetry
- snoring
- body movement
- heart rate
- oronasal flow

265

What is full polysomnography

Limited sleep study + eeg and emg

266

Give some of the lifestyle changes a patient with obstructive sleep apnoea can make

- weight loss
- sleep in decubitus position
- avoid evening alcohol

267

How do you treat significant obstructive sleep apnoea

CPAP +/- niv prior to CPAP if acidotic

268

How does CPAP help with obstructive sleep apnoea

Opens collapsed alveoli, prevents airway collapse and improves v/q matching

269

What is fio2

Fraction of inspired oxygen

270

What is the difference between CPAP and BIPAP

CPAP provides constant positive pressure during inspiration and expiration
BIPAP applies two pressures - IPAP during inspiration and EPAP during expiration

271

List the different histological types of lung cancer

- squamous cell
- Adenocarcinoma
- small (oat) cell
- large cell

272

What sign may you see in the eyes of a patient with lung cancer

Horner syndrome

273

Patients with lung cancer may have svc obstruction, what are the characteristic signs in a patient with svc obstruction

Oedema of the face and arms, swollen chest veins

274

List some areas of the body where lung cancer may spread

Pleura
Liver
Adrenals
Brain
Bone

275

List risk factors for lung cancer

- large number of years smoking
- airflow obstruction
- increasing age
- family history of lung cancer
- exposure to carcinogens e.g. Asbestos

276

What is 0 on the WHO scale for performance status

Normal - fully active without restriction

277

What is 1 on the WHO scale of performance status

Restricted in physically strenuous activity but ambulatory and able to carry out light work e.g. Housework

278

What is stage 2 on the WHO performance scale

Ambulatory and capable of all self care but unable to carry out work activities

279

What is grade 3 on the WHO scale for performance status

Capable of limited self care, confined to bed or chair more than half of waking hours

280

What is grade 4 on the WHO performance scale

Completely disabled, cannot self care and totally co fed to bed/chair

281

What is stage 5 on the WHO performance status

Dead

282

How do you investigate possible lung cancer spread to the lymph nodes

Aspiration

283

What bloods would you do to investigate lung cancer

FBC, u+e, calcium, LFTs, INR

284

What signs do you look for on CXR

- mass
- lung collapse
- pleural effusion
- consolidation
- hilar enlargement

285

Where on a CXR would you look for bone secondaries

Ribs

286

What would you use a ct scan for in patients with lung cancer

Staging, Tnm

287

What cytology would you perform on a patient with lung cancer

Sputum and pleural fluid

288

What are some of the local nerve complications of lung cancer

- recurrent laryngeal nerve palsy
- phrenic nerve palsy
- Horner's syndrome

289

What type of tumour can cause Horner's syndrome

Pancoasts tumour

290

What are some of the heart-related complications of lung cancer

Pericarditis
AF

291

If lung cancer has spread to the bone, what findings may there be

Raised calcium
Anaemia

292

How do you treat stage I/II non small cell lung cancer

Curative surgery,
or curative radiotherapy if Resp reserve is poor

293

How do you treat stage III non small cell lung cancer

Surgery and adjuvant chemo if patient is fit

294

How do you treat patients with stage III/IV non small cell lung cancer

Chemotherapy

295

How is small cell lung cancer treated

As it has a rapid growth rate, it is almost always too extensive for surgery at the time of diagnosis. Mainstay treatment is chemo, palliative therapy.

296

List some of the supportive treatments given to lung cancer patients

Analgesia
Steroids
Antiemetics
Antitussive
Bronchodilator

297

What is the definition of type 1 respiratory failure

Hypoxia (pao2 less than 8kpa), with normal or low paco2. Caused primarily by ventilation perfusion mismatch

298

List some conditions that can lead to type 1 respiratory failure

1) pneumonia
2) pulmonary oedema
3) ARDS
4) PE
5) fibrosing alveolitis
6) emphysema
7) asthma

299

Define type 2 respiratory failure

Hypoxia (pao2 less than 8kpa) with hypercapnia (paco2 >6kpa), caused by alveolar hypoventilation +/- vq mismatch

300

What are some pulmonary diseases that can lead to type 2 Resp failure

Asthma
COPD
Obstructive sleep aponea
Pneumonia
Pulmonary fibrosis

301

List some of the causes of decreased respiratory drive that can cause type 2 respiratory failure

Sedative drugs
CNS tumour
Trauma

302

List some of the neuromuscular diseases that can cause type 2 respiratory failure

Cervical cord lesion
Diaphragmatic paralysis
Poliomyelitis
Myasthenia gravis
Guillain barre syndrome

303

Give some thoracic wall diseases that can cause type 2 respiratory failure

Kyphosis
Scoliosis
Flail chest

304

What is guillain barre syndrome

Rapid onset muscle weakness due to damage to peripheral nervous system

305

In respiratory failure, list some of the signs and symptoms associated with the hypoxic effects of the condition

- dyspnoea
- restlessness
- agitation
- confusion
- central cyanosis

306

In respiratory failure, what are some of the sequelae to long term hypoxia

- polycythaemia
- pulmonary hypotension
- cor pulmonale

307

In respiratory failure, list some of the features of hypercapnia

- headache
- peripheral vasodilatation
- tachycardia
- bounding pulse
- tremor/flap
- papilloedema
- confusion, drowsiness
- coma

308

Which investigations would you perform on a patient with respiratory failure

FBC, u+e, CRP
ABG
CXR
Sputum and blood cultures if febrile
Spirometry

309

How do you treat type 1 respiratory failure

Venturi mask delivering 35-60% oxygen via face mask
Assisted ventilation if pao2

310

How do you manage type 2 respiratory failure

Treat underlying cause
Controlled O2 therapy starting at 24% via Venturi mask
Recheck abg after 20mins
If paco2 is steady or lower, then increase O2 to 28%

311

What measures are taken to control type 2 respiratory failure if giving lower flows of oxygen via a Venturi mask isnt reaching the desired effects

Consider respiratory stimulant or assisted ventilation if still hypoxic and paco2 has risen over 1.5 kpa
If all else fails, intubation and ventilation

312

When would you consider doing an ABG

1) unexpected deterioration in the ill patient
2) acute exacerbation of chronic chest infection
3) impaired consciousness
4) impaired respiratory effort
5) signs of co2 retention
6) cyanosis, confusion, visual hallucinations
7) validation of pulse oximetry

313

What is the management of COPD patients with breathlessness and exercise limitation

Short acting beta agonists
Short acting muscarinic antagonists

314

What is the treatment for COPD patients with occasional exacerbations or persistent breathlessness

If fev >50 then LABA + LAMA instead of SAMA
If fev

315

How do you treat COPD patients with persistent exacerbations of COPD and breathlessness

LABA + ICS if fev1 >50
LAMA + LABA + ICS if fev1

316

What is Ltot

Long term oxygen therapy - where continuous home oxygen therapy is given to patients with chronic hypoxaemia of

317

List some of the indications for Ltot

COPD
ILD
CF
Bronchiactesis
Chronic HF

318

If you're not sure as to whether a patient has pneumonia or TB, how do you go on to treat them

Treat as if pneumonia as per curb65 while investigation for pneumonia

319

TB cultures can take weeks to come back, so how do you treat a patient with highly suspected TB in the meanwhile

Start anti TB therapy and send off sputum cultures at the same time (looking for acid fast bacilli etc)

320

List absolute contraindications for thrombolysis

- haemorrhagic/ischaemic stroke

321

How does aminophylline work

Inhibits phosphodiesterase, increasing camp levels and causing bronchodilation. Inhibits TNF alpha and leukotriene synthesis

322

Levels of which intracellular molecule do b2 agonists increase

Camp

323

List tow drug classes that can worsen asthma

Beta blockers, NSAIDs

324

What is tryptase a marker of, hence should be measured in which emergency lung condition

Mast cell activation - measure serum tryptase in anaphylaxis

325

What is LTOT used for

Preventing organ damage caused by prolonged hypoxia, for survival benefit

326

How many hours a day is LTOT used for

Most of the day - at least 16 hours or more

327

What are the criteria for LTOT treatment

Po2 consistently below 7.3 kpa or below 8kpa with cor pulmonale
Must be non smokers and not retain high levels of co2

328

Describe the cycle that COPD patients go through, that Pulmonary Rehabilitation tires to break

Feel breathless -> avoid activities that make you breathless -> do less -> muscles weaken -> get more breathless -> feel depressed -> avoid activities that make you feel breathless

329

How many weeks does the MDT pulmonary rehabilitation programme last

6-12 weeks

330

What does the pulmonary rehabilitation programme involve

Supervised exercise, unsupervised home exercise, nutritional advice, disease education

331

What are the gold criteria for COPD severity classification

Mild - fev higher or equal to 80%
Mod - fev 50-80%
Sev - fev

332

List the bacteria most commonly responsible for atypical pneumonia

Mycoplasma pneumoniae,
Chlamydia pneumoniae
Legionella pneumophilia

333

List the viruses most common in community acquired and atypical pneumonia

Influenza virus, RSV, adenovirus

334

What are the four main antibiotics used to treat pneumonia empirically

1) doxycycline
2) clarithromycin or azithromycin
3) levofloxacin

335

What are some of the vaccines which may be given to certain individuals to prevent community acquired pneumonia

Pneumococcal vaccine, flu vaccine

336

If a pneumonia patient has a high curb 65 score, which extra tests should you do on them

Atypical pneumonia screen, serology and urine legionella test

337

What is sarcoidosis

Multisystemic granulomatous disorder of unknown cause, usually affecting afrocarribbeans and Northern Europeans

338

How does acute sarcoidosis tend to present

Erythema nodosum +/- polyarthralgia

339

How does pulmonary disease sarcoidosis present on CXR

Bilateral hilar lymphadenopathy +/- pulmonary infiltrates or fibrosis

340

What does tissue biopsy in sarcoidosis show

Non Caseating granuloma

341

How is acute sarcoidosis managed

As it'll usually recover spontaneously, NSAIDs and best rest are recommended

342

When are steroids indicated in sarcoidosis

If it is causing parenchymal lung disease or affecting other systems e,g, causing uveitis or hypercalcaemia

343

What is allergic bronchopulmonary aspergillosis

Hypersensitivity reactions to aspergillus fumigatus causing brocnhoconstriction when early and bronchiactesis if chronic

344

How is allergic boncropulmonary aspergillosis treated

Prednisolone

345

What is an aspergilloma

A fungus collection inside a cavity

346

How is aspergilloma treated

Surgical excision

347

What is cor pulmonale

Right heart failure due to chronic pulmonary arterial hypertension

348

How do you manage cor pulmonale

- treat underlying cause e.g. COPD
- treat resp failure
- assess for LTOT
- treat hf with diuretics etc
- consider venesection if haemorrhoids is >55%

349

What is he a-a gradient in the lungs

Alveolar:arterial gradient
This is the measure of difference between alveolar O2 conc and arterial O2 conc

350

What does A-a gradient determine

Is the problem in oxygenation is intra- or extra pulmonary

351

What is the healthy A-a gradient in young people

Less than 2 kpa difference

352

What is the healthy A-a gradient in older people

Less than 4kpa gradient

353

What does an A-a gradient of >4 kpa indicate

Lung pathology is present

354

How is the aveolar partial pressure of oxygen measured, in order to then work out the A-a gradient

Alveolar partial pressure of oxygen = (room air oxygen partial pressure (usually 20kpa)) - (paco2 in blood/0.8)
Then this PA02 value - pao2 in blood gives you the A-a gradient

355

What is the typical apprance on blood film of a patient infected with CMV

Owls eye cells

356

What is chlorpheniramine

Antihistamine

357

What CXR signs may be seen in a patient with PE

Small pleural effusion,
Wedge shaped infarct (much later)

358

What are the nice guidelines for PE and ctpa management

If wells score over 4, PE is likely so assess for ctpa.
If ctpa/(v/q) unavailable/unsuitable then immediately thrombolyse
Ctpa diagnoses PE, which can then be treated appropriately according to guidelines. If ctpa doesn't diagnose PE then assess for DVT likeliness
If avail ale

359

How long do patients who have had a PE have to wait before they can fly

At least one week following normalisation of CXR before they're allowed to fly

360

What is the most common cause of monophonic wheeze

Bronchial carcinoma

361

When a patient who has had an asthma exacerbation is discharged, what steps are taken

- asthma nurse review - inhaler technique, adherence
- asthma action plan
- pefr over 75%
- stop NEBs 1 day prior to discharge
- provide pefr
- at least 5 days of oral pred
- gp follow up in 2 working days
- Resp clinic follow up in 4 weeks
- consider psychosocial

362

Describe the pulmonary rehabilitation programme

Aims to break the cycle of breathlessness and I activity patients with COPD undergo, with a 6-12 week MDT approach, where a patient is encouraged to do supervised exercise, home exercises and nutritional and disease education is given

363

What does giving Ltot avoid in patients

Hypoxaemic damage to kidneys or heart

364

Which condition can give coarse end inspiratory crepts on auscultation

Bronchiactesis

365

What is kussmauls breathing

Deep and laboured breathe , often associated with ps every metabolic acidosis

366

List the different symptoms related to para neoplastic syndrome in lung tumours

Clubbing, hypercalcaemia, anaemia, SIADH, cushings, thromboembolic disease

367

How do you treat mild community acquired pneumonia

Amoxicillin or Doxycycline or clarithromycin

368

How do you treat moderate community acquired pneumonia

Amoxicillin and either clarithromycin or doxycycline

369

How do you treat severe community acquired pneumonia

Coamoxiclav or cefuroxime + clarithromycin.
Add flucloxacillin if staph aureus suspected
Or add vancomycin if mrsa suspected

370

What antibiotic do you consider adding in patients with pneumonia in whom you suspect legionella infection

Rifampicin

371

Which antibiotic do you add in patients with pneumonia in whom you suspect chlamydia as a cause

Tetracycline

372

Which antibiotic do you consider adding in a patient with pneumonia in whom you suspect pneumocystis jirovecii

Cotrimoxazole

373

How do you treat hospital acquired pneumonia

Aminoglycoside + antipseudomonal penicillin/cephalosporin