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1
Q

What can cause upper zone lung fibrosis

A 
TB
extrinsic allergic alveolitis
sarcoidosis
silicosis
ank spond
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2
Q

What can cause lower zone lung fibrosis

A

IPF
drugs
asbestosis

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3
Q

What drugs can cause lower zone lung fibrosis

A

amiodarone
methotrexate
bleomycin
nitrofurantoin

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4
Q

What is idiopathic pulmonary fibrosis

A

progressive fibrosis of the interstitial alveolar tissue
excessive collagen deposition
no known cause

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5
Q

Who is IPF most common in

A

men aged 50-70

smokers

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6
Q

What are the symptoms of IPF

A

dry cough

SOB

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7
Q

What are the signs of IPF

A

fine end-inspiratory bibasal crackles

clubbing

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8
Q

How should a patient with suspected IPF be investigated?

A 
Bedside
Bloods: ABG, ANA, CRP
Micro: 
Imaging: CXR, HRCT, 
Special tests: spirometry, TLCO
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9
Q

What are the common findings on CXR in IPF

A

reticular shadowing
small, irregular, peripheral opacities - ground-glass
decreased lung volume
honeycombing

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10
Q

What are the common findings on HRCT in IPF

A

reticular opacities
honeycombing

essential for diagnosis!

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11
Q

What are the common findings on spirometry in IPF

A

reduced FVC
reduced FEV1
FEV1/FVC normal/increased

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12
Q

What What are the common findings on TLCO in spirometry

A

reduced transfer factor

impaired gas exchange

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13
Q

What is the management of IPF

A

pulmonary rehabilitation
oxygen

clinical trial
lung transplant

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14
Q

What is the prognosis in IPF

A

50% 5 year survival rate

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15
Q

What investigations should be carried out in suspected COPD

A 
Bedside: BMI, ECG
Bloods: FBC, 
Micro
Imaging: CXR
Special tests: post bronchodilator spirometry
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16
Q

State the MRC Dyspnoea Scale grades

A 
1 = not breathless
2 = breathless on walking up hill
3 = walks slowly
4 = breathless after 100 metres/ few mins
5 = unable to leave house
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17
Q

How are the stages of COPD defines

A

perventage predicted of FEV1

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18
Q

State the stages of COPD defined by the FEV1

A 
>80% = mild
50-79% = moderate
30-49% = severe
<30% = very severe
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19
Q

What are the signs of COPD on CXR

A

increased lung volume
flattened diaphragm
bullae

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20
Q

Describe the steps in the pharmacological management of stable COPD

A
  1. LABA/LAMA
  2. if FEV1 >50% = LABA/LAMA
    if FEV1 <50% = LABA+ICS/LAMA
  3. if LABA -> LABA+ICS
    if LAMA -> LABA+ICS + LAMA
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21
Q

What general measures are involved in the management of COPD

A

pulmonary rehabilitation
stop smoking
influenza vaccine
pneumococcal vaccine

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22
Q

What bacteria are most commonly present in acute exacerbation of COPD

A

Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis

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23
Q

Descrebe the steps in management of an acute exacerbation of COPD

A 
admit
nebulised salbutamol and ipatropium
oxygen - if known hypercapnic, 28% venturi(white) at 4l
IV hydrocortisone and oral presnisolone
Abx if sputum purulent - doxycycline
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24
Q

What is the rationale behind LTOT in COPD

A

maintaining PaO2 >8kPa for >15hours per day increases the 3yr survival rate by 50%

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25
What are the criteria for LTOT in COPD
PaO2 <7.3 on two separate occasions greater then 3 weeks apart PaO2 7.3-8 + evidence of pulmonary hypertension, polycythaemia, peripheral oedema, nocturnal hypoxia on two separate occasions greater then 3 weeks apart
26
Which patients with COPD should be assessed for LTOT
very severe airflow obstruction (FEV1 < 30% predicted), 'considered' for patients with severe airflow obstruction (FEV1 30-49% predicted) cyanosis polycythaemia peripheral oedema raised JVP oxygen saturations less than or equal to 92% on room air
27
What are the diagnostic criteria should be used when assessing a patient with suspected COPD?
FEV1/FVC <70% symptoms!
28
What is the difference between a primary and secondary pneumothrax?
``` primary = no underlying disease secondary = occurs in presence of underlying disease` ```
29
What is the difference between a pneumothorax and a tension pneumothorax?
tension = trachea deviated away from affected side. Air cannot leave pleural cavity during expirations due to valve like flap in parietal pleura.
30
What tests should be done in suspected pneumothorax?
ABG | CXR
31
What is the management of a primary pneumothorax?
>2cm or breathless = aspiration. successful (<2cm) = discharge, r/v OPD in 2-4wks unsuccessful = admit, chest drain <2cm, not breathless = discharge, OPD in 2-4wks
32
What is the management of a secondary pneumothorax?
>2cm, breathless = chest drain 1-2cm = aspirate. success (<1cm) = admit, oxygen, observe 24h unsuccessful = chest drain <1cm = admit, oxygen, observe 24h
33
How do you aspirate a pneumothorax
14-16G cannula 2nd ICS in midclavicular line (superior to 3rd rib) remove needle connect cannula to 3 way tap and 50ml syringe aspirate! CXR to confirm resolution
34
What are the signs of a working chest drain?
swinging bubbling water bottle below patient!
35
What is the bacterium involved in TB
Mycobacterium tuberculosis
36
What are the characteristics of the Mycobacterium tuberculosis
aerobe rod shaped waxy - acid fast
37
Describe how the ghon focus forms in TB
``` Macrophages phagocytose bacteria Tb can inhibit phagosome and lysosome fusing TB proliferates granuloma forms caseous necrosis ```
38
What are the cells in a granuloma
epitheloid histiocytes
39
What is a Ghon complex
ghon focus plus hilar lymph node involvement
40
What is a Ranke complex
fibrosis and calcification of Ghon complex
41
What can cause dormant TB to become reactivated
``` steroids HIV malnutrition chronic renal failure solid organ transplantation with immunosuppression IVDU haematological malignancy anti-TNF treatment ```
42
Where is TB often located in the lungs?
upper lobes
43
Where can TB spread to?
``` brain - meningitis kidneys - sterile pyuria spine - Pott's adrenal - addison's liver - hepatitis ```
44
What investigations should be done in suspected TB
sputum cultures - 3x | CXR
45
What are the features of TB on CXR
``` hilar lymphadenopathy consolidation in upper lobes Ghon focus upper zone fibrosis pleural effusion in primary ```
46
What is the treatment for active TB
Rifampicin Isoniazid Pyramidazole Ethambutol R+I for 6m, P+E for first 2 months
47
What is the treatment for latent TB
Rifampicin and Isoniazid for 3m | Isoniazid for 6m
48
What are the side effects of rifampicin
hepatitis, orange secretions
49
What are the side effects of isoniazid
peripheral neuropathy hepatitis, agranulocytosis
50
What are the side effects of pyrazinamide
hyperuricaemia causing gout arthralgia, myalgia hepatitis
51
What are the side effects of ethambutol
optic neuritis
52
What tests do you need to do before initiating treatment of TB
LFTs visual acuity FBC
53
What is the difference between acute bronchitis and pneumonia?
acute bronchitis is a transient inflammation of the trachea and major bronchi associated with oedema and mucus production pneumonia is an acute infection of the lung parenchyma
54
State the most common causes of CAP
Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus
55
What are some atypical causes of CAP
Mycoplasma pneumoniae Klebsiella pneumoniae Legionella pneumophilia Pneumocystis jiroveci
56
What are the common features of pneumonia causes by Streptococcus pneumoniae
fever rapid onset pleuritic chest pain cold sores!
57
Which group of people is Klebsiella pneumoniae most common in?
alcoholics
58
Which bacterial cause of pneumonia often follows influenza?
staph aureus
59
What chsnegs are often seen in teh blood results of a patient with Legionella pneumophilia?
lymphopaenia hyponatraemia deranged LFTs
60
What are the classical features of Pneumocystis jiroveci
HIV positive dry cough no chest signs desaturate on exercise
61
What are the most common causes of HAP
gram negative enterobacteria staph aureus Moraxella catarrhalis
62
What are the most common causes of pneumonia in an immunocompromised patient?
``` Strep pneumoniae Haemophilus influenzae Staph aureus Moraxella catarrhalis Mycoplasma pneumoniae Pneumocystis jiroveci CMV HSV ```
63
What investigations are carried out in suspected pneumonia?
urine testing for pneumococcal antigen FBC, U+E, LFTs, CRP blood cultures, sputum cultures CXR
64
What is the immediate management of a patient with penumonia
O2 if desaturated IV fluids if dehydrated analgesia for pleuritic pain antibiotics!
65
What are the values used for CURB-65
``` Confusion Urea >7 RR >30 BP <90/60 >65 ```
66
How does management change depending on the CURB-65 score?
<=1 manage at home >=2 admission to hospital >=3 consider ITU/HDU
67
What is antibiotic treatment for mild/moderate pneumonia
amoxicillin 500mg-1g/8h oral for 5 days
68
What is antibiotic treatment for severe pneumonia
7-10days of co-amoxicav 1.2g/8g IV + clarithromycin 500mg/12h IV
69
What is antibiotic treatment for hospital acquired pneumonia
gentamicin plus ceftriaxone
70
What is the most common cause of PE
DVT
71
What are the most common signs of PE
increased RR increased HR crackles on auscultation pyrexia
72
What investigations should be carried out in suspected PE
Well's score ECG FBC, U+E, clotting, ABG CXR to exclude other diagnoses
73
State how to calculate the PE Well's score
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3 An alternative diagnosis is less likely than PE 3 Heart rate > 100 beats per minute 1.5 Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5 Previous DVT/PE 1.5 Haemoptysis 1 Malignancy (on treatment, treated in the last 6 months, or palliative) 1
74
How does the Wells score for PE change the investigation of PE
>4 = PE likely. urgent CTPA needed <=4 = PE unlikely. do d-dimer. if negative, d-dimer ruled out if positive, d-dimer not ruled out. arranged CTPA
75
What is the management of a confirmed PE
LMWH - enoxaparin 1.5mg/kg/24h plus warfarin stop LMWH when INR 2-3 for over 24hrs warfarin for 3m if provoked, 6m if unprovoked
76
What is the management of a massive PE
``` SENIOR HELP oxygen IV access morphine and antiemetic IV colloids thrombolysis ```
77
What is a massive PE
PE with presence of circulatory failure
78
When would V/Q testing be used in investigation of PE
if severe renal failure or allergy to contrast
79
Describe the pathophysiology of asthma
chronic inflammation of the airways due to a hypersensitivity reaction. infiltration of eosinophils, TH2 cells and mast cells into the mucosa release of histamine, leukotrienes and prostaglandins leading to bronchoconstriction and increased mucus production airway hypersensetivity in the long term, there is mucosal oedema and thickened basement membrane
80
What are soem of the risk factors for asthma
``` developed country history of atopy urban areas premature viral infection early in life ```
81
What are the symptoms of asthma
cough - dry, worse at night chest tightness breathlessness
82
What are the potential triggers of asthma exacerbation
dust, pet hair, pollen air pollutants, smoking, cold air aspirin, B blockers occupation
83
What are the signs of chronic asthma
``` increased RR hyperinflated chest use of accessory muscles intercostal recession expiratory high pitched wheeze ```
84
What investigations should be carried out in suspected chronic asthma
peak flow monitoring spirometry with bronchodilator reversibility test fractional exhaled nitric oxide
85
What are the expected findings on peak flow monitoring in asthma
diurnal variation - morning dipping
86
What are the expected findings on spirometry with bronchodilator reversibility testing in asthma
FEV1/FVC <70% pre bronchodilator improvement of >=12% post bronchodilator
87
What is a fractional exhaled nitric oxide test?
measurement of nitric oxide synthases in breath there are 3 types of nitric oxide synthases (NOS) - One of the types is inducible (iNOS) and levels tend to rise in inflammatory cells, particularly eosinophils. Levels of NO therefore typically correlate with levels of inflammation.
88
What are the expected findings on fractional exhaled nitric oxide test in asthma
raised levels due to inflammation
89
What are the steps in management of chronic asthma according to NICE
1. SABA reliever therapy 2. + low dose ICS 3. + LTRA 4. + LABA 5. lose dose MART 6. medium dose MART 7. high dose ICS or LAMA or theophylline
90
What is a LTRA
leukotriene receptor antagonist eg. monteleukast reduced smooth muscle cell constriction, mucus production and eosinophils
91
What is a MART
Maintenance and reliever therapy = combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
92
Define a moderate acute asthma attack
PEFR 50-75% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm
93
Define a severe acute asthma attack
PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm
94
Define a life threatening asthma attack
any one of: ``` PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma ```
95
Define a near fatal asthma attack
rise in PaCO2 or requiring ventilation
96
What investigations should be carried out in acute asthma attack
``` PEFR, ECG, pulse oximetry ABG FBC, U+E, CRP, cultures ?CXR ```
97
What is the management of severe acute asthma
O2 if sats <92% salbutamol 5mg nebulised with o2 ervy 15 mins hydrocortisone 100mg IV ipatropium bromide if response to beta agonists is poor Abx if due to infection magnesium sulphate IV if poor response
98
What monitoring needs to be done with salbutamol therapy in acute asthma
ECG - tachyarrythmias potassium - hypokalaemia peak flows! ABGs
99
What are the indications for admission to ITU in severe asthma attack?
``` rising PaCO2 low PaO2 exhaustion, drowsiness, coma respiratory arrest not responding to therapy ```
100
When would it be right to admit a patient with a moderate acute asthma exacerbation to hospital?
if they have had a previous near fatal asthma attack
101
When would you consider stepping up chronic asthma therapy
using SABA three times a week or more, being symptomatic three times a week or more, experiencing night-time symptoms at least once a week, has had an asthma attack in the last 2 years.
102
Describe the pathophysiology of bronchiectasis
chronic infection and inflammation leads to dilation of the bronchial walls and bronchioles
103
What are some causes of bronchiectasis
infections: pneumonia, TB, whooping cough, measles CF bronchial obstruction e.g. lung cancer/foreign body immune deficiency: selective IgA, hypogammaglobulinaemia allergic bronchopulmonary aspergillosis (ABPA) ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndrome
104
What are the symptoms of bronchiectasis
cough sputum haemoptysis
105
What are the signs of bronchiectasis
``` clubbing anaemia coarse crackles on inspiration cor pulmonale - raised JVP, peripheral oedema smelly breath - foetor ```
106
What investigations need to be carried out for bronchiectasis
CXR, HRCT spirometry with reversibility bronchoscopy
107
What are the typical findings on CXR for bronchiectasis
tram lines
108
What are the typical findings on HRCT for bronchiectasis
signet ring sign
109
What is the management of bronchiectasis
chest physio - twice daily postural drainage antibiotics in exacerbation (may need to be long term if severe) bronchodilators if they help surgery if localised disease
110
What are some complications of bronchiectasis
pleural effusion pneumothorax pneumonia cerebral abscess
111
What are the most common organisms found in the sputum of bronchiectasis
Haemophilus influenzae (most common) Pseudomonas aeruginosa Klebsiella spp. Streptococcus pneumoniae
112
Name the types of lung cancer
small cell squamous cell adenocarcinoma large cell
113
Which lung cancer is more common in non-smokers
adenocarcinoma
114
Which lung cancer is PTHrP released in
squamous cell
115
Which lung cancer is ADH released in
small cell
116
Which lung cancer is ACTH released in
small cell
117
Which lung cancer is clubbing more common in
squamous
118
Which lung cancers metastasise early and late
``` early = small and large late = squamous and adeno ```
119
What are the most common symptoms of lung cancer
``` cough hamoptysis dyspnoea chest pain weight loss recurrent pneumonia ```
120
What are the signs of lung cancer
cachexia clubbing supraclavicular/axillary lymph nodes
121
What are some potential complications of lung cancer
``` SVC obstruction phrenic nerve palsy recurrent laryngeal nerve palsy Horner's oesophagel compression ```
122
What are the features of SVC obstruction
swelling of face and upper limbs | dilated veins
123
What are the features of phrenic nerve palsy
raised hemidiaphragm on CXR | dyspnoea
124
What are the features of recurrent laryngeal nerve palsy
hoarse voice | aspiration
125
What causes Horner's syndrome in lung cancer
palsy of sympathetic chain from Pancoast tumour in apex of lung
126
What are the features of Horner's syndrome
hemifacial anhidrosis miosis - small pupil ptosis
127
What investigations should be carried out in suspected lung cancer
``` CXR FBC, U+E, bone profile, ACTH and cortisol levels, LFTs, INR CXR staging CT PET scan to look for metastasis ```
128
What is the WHO performance status scale
``` 0 = normal activity 1 = symptomatic, but ambulatory 2 = >50% normal activity, some help with care 3 = <50% normal activity, needs nursing care 4 = bed bound ```
129
What is the treatment, according to stage, of lung cancer
I or II = curative surgery IIIa = curative surgery + adjunct chemo III or IV + performance status 0-2 = chemo others palliative
130
What kind of things can be done for palliative care in lung cancer
radiotherapy - reduce size of tumour | SVC stent
131
What are the common adverse effects of salbutamol
``` angiooedema tremor palpitations nausea headache taste alteration risk of hypokalaemia ```
132
Why might salbutamol be contraindicated?
hypokalaemia hypersensetivity pre-eclampsia
133
What is the mechanism of action of theophylline
xanthine | relaxes smooth muscle - acting mainly as a bronchodilator and vasodilator
134
What can affect the plasma-theophylline concentration
plasma-theophylline concentration is increased in: heart failure, hepatic impairment viral infections. The plasma-theophylline concentration is decreased: in smokers by alcohol consumption. Differences in the half-life of theophylline are important because the toxic dose is close to the therapeutic dose.
135
What problems can theophyline cayse
hypokalaemia | overdose can be fatal
136
What is the presentation of theophylline overdose
``` vomiting (which may be severe and intractable), agitation, restlessness, dilated pupils, sinus tachycardia, hyperglycaemia. ``` ``` More serious effects are haematemesis, convulsions supraventricular and ventricular arrhythmias. Severe hypokalaemia may develop rapidly. ```
137
What are the key side effects if glucocorticoids?
``` diabetes osteoporosis avascular necrosis of the femoral head. infections Muscle wasting (proximal myopathy) can also occur. peptic ulceration and perforation. Psychiatric reactions may also occur. ```
138
What should you tell a patient when presciribing prednisolone?
increased risk of infections - see doctor straighwaay steroid treatment card if diabetic, check blood more frequently some immunisatoins might not be suitable - check! see doctor if any worrying side effects
139
Describe the pathophysiology of COPD
progressive airflow obstruction due to mucous gland hyperplasia and loss of cilial functon ``` emphysema = alveolar wall destruction causing irreversible enlargement of airspaces distal to teh terminal bronchioles bronchitis = chronic inflammation and fibrosis of small airways due to lymphocytes and macrophages ```
140
Why do people with COPD develop ankle oedema
``` hypoxic vasocontriction in lungs pulmonary hypertension and venous congestion increased pressure in right ventricle increased preload venous ```
141
Why might uncontrolled oxygen therapy be dangerous in COPD
chronic hypercapnia - compensated for by HCO3- switch to hypoxic respiratory drive increased oxygen leads to decreased ventilation worsens hypercapnia
142
What key questions would you ask a patient asthma when reviewing them
``` cough SOB how often using inhalers inhaler technique nocturnal sx exposure to tobacco smoke school/work/home interference asthma attacks steroids? do they have self-management plan ```
143
What should be monitored in those taking long term steroids?
Blood pressure. Urine or blood sugar (measured by HbA1c). Cholesterol. Bone mineral density. Vision (to assess for cataracts and glaucoma).
144
What is Allergic Bronchopulmonary Aspergillosis
allergic reaction to Aspergillus fumigatus spores | hypersensitivity reaction I or III
145
What are the features of Allergic Bronchopulmonary Aspergillosis
first bronchoconstriction - wheeze, cough, SOB | then bronchiectasis - sputum
146
What are the findings on investigation of Allergic Bronchopulmonary Aspergillosis
eosinophilia rasied serum IgE aspergillus in sputum positive radioallergosorbent (RAST) test to Aspergillus CXR: transient segmental collapse or consolidation, bronchiectasis
147
What is an asthma managemnt plan
written plan for helping patients to: recognise worsen asthma - sx or peak flow initiate changes to treatment when symptoms change eg. seeking emergency help, starting oral steroids, restarting or temporarily increasing inhaled corticosteroid know how and when to access medical help
148
What are some systemic complications of CAP
sepsis brain abscess pericarditis cholestatic jaundice
149
What are some local complications of CAP
pleural effusion empyema lung abscess respiratory failure
150
What is the differential diagnosis for a pleural effusion associated with CAP
empyema' | secondary to lung cancer
151
What is a pleural effusion
collection of excess fluid in the pleural space
152
What is the pathophysiology of a transudate pleural effusion
increased hydrostatic or decreased oncotic pressure leading to too much fluid leaving capillaries and entering pleural space
153
What are some causes of a transudate pleural effusion
heart failure cirrhosis nephrotic syndrome
154
What defines a transudate or an exudate
the amount of protein in the fluid ``` transudate = <30g/L exudate = >30g/L ```
155
What is the pathophysiology of an exudate pleural effusion
inflammation of the pulmonary capillaries leads to fluids, immune cells and proteins leaking out into the pleural space
156
What causes an exudate pleural effusion
infection malignancy systemic inflammation - RA, SLE, pancreatitis
157
When is Light's criteria used?
to decide if a pleural effusion is an exudate or a transudate when protein levels are 25-35g/L
158
State Light's criteria
fluid protein:serum protein >0.5 fluid LDH:serium LDH >0.6 fluid LDH > 2/3 normal upper limit serum LDH
159
What are the symptoms of pleural effusion
pain on inspiration SOB cough
160
What are the signs of pleural effusion
dull to percussion reduced chest expansion reduced breath sounds bronchial breathing
161
What investigations should be done in pleural effusion
urine dipstick ECG FBC, U+E, LFTs, CRP CXR, echo, contrast staging CT if ?malignant US guided Pleural aspiration
162
What are the signs on CXR of pleural effusion
blunting of costophrenic angles | meniscus sign
163
What should the fluid collected on pleural aspiration from pleural effusion be tested for?
biochen: protein, LDH, pH cytology microbiology immunology: RF, ANA
164
What is the management of pleural effusion
treat the underlying cause | ?drain using chest time
165
What can be done for recurrent pleural effusions
recurrent aspiration pleurodesis indwelling permanant catheter
166
State the pathophysiology of sarcoidosis
multisystem granulomatous condition with unknown aetiology
167
Who is sarcioidosis most common in
females 20-40y afro-caribbean
168
What are the features of acute sarcoidosis
erythema nodosum arthralgia bilateral hilar lymphadenopathy
169
How many cases of acute sarcoidosis resolve spntaneously within a year
80%
170
What are the features of chronic sarcoidosis
progressive breathlessness malaise weight loss
171
What investigation sshould be done in sarcoidosis
FBC, ESR, calcium CXR transbronchial biopsy
172
What are the blood test findings in sarcoidosis
decreased lymphocytes low platelets raised ESR raised calcium - due to abnormal vit D metabolism
173
What are the CXR stages of sarcoidosis
0 = no change 1 - BHL 2 - BHL + pulmonary infiltrates' 3 - pulmonary infiltrates, no BHL
174
What is seen on histology in sarciodosis
non-caseaeting granulomas
175
What is the treatment of sarciodosis
pain relief - NSAIDs if good prognosis (BHL + erythema nodosum) steroids chloroquine
176
When are steroids used in teh treatment of sarciodosis
if: stage 2/3 + moderate/severe or progessive symptoms eye, heart or neurological involvement raised Calcium
177
What is the stepwise management of paediatric asthma (5-17y) according to NICE
``` SABA + paed low dose ICS +LTRA + LABA stop LABA, atart MART (paed medium) increase MART to high dose or start theophylline SR. ```

Finals (32 decks)

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