resp

Question 1

causes of pleural effusion

Answer 1

exudate (protein > 35g/dl): infection (pneumonia), inflammation (SLE, rheumatoid arthritis), malignancy (lung cancer, mets)
transudate (protein < 25g/dl): cardiac, liver, renal failure

Question 2

causes of ILD

Answer 2

idiopathic pulmonary fibrosis
occupational / environmental: extrinsic allergic alveolitis / pneumoconiosis
drugs: methotrexate, amiodarone
inflammatory: SLE, RA, sarcoidosis, ank spond, systemic sclerosis
other: radiation

Question 3

ILD investigations

Answer 3

bloods: FBC, CRP/ESR,
serology: RF, ANA, anti-CCP, anti-Jo
lung function tests (restrictive pattern)
CXR (initial)
high-res CT → honeycombing
bronchoscopy + biopsy (diagnostic)

Question 4

definition of COPD

Answer 4

emphysema + chronic bronchitis
emphysema = enlargement of alveolar spaces
chronic bronchitis = chronic productive cough for at least 3mths/year for at least 2 years

Question 5

signs of hyperexpansion

Answer 5

reduced cricosternal distances (normal = 3 fingers) 
tracheal tug
barrel chest
reduced chest expansion 
loss of cardiac dullness
displaced liver edge

Question 6

signs on examination for COPD

Answer 6

hyperexpansion
hyperresonance
reduced breath sounds + vocal resonance 
coarse crackles 
expiratory wheeze

Question 7

causes type 1 resp failure

Answer 7

ventilation perfusion mismatch:
pneumonia
PE
pulmonary oedema 
asthma
ARDS

Question 8

causes type 2 resp failure

Answer 8

resp disease: COPD, asthma, pneumonia, obstructive sleep apnoea
reduced resp drive: sedatives, CNS tumour / trauma
neuromuscular disease: guillain-barre, myasthenia gravis
thoracic wall disease: flail chest, kyphoscoliosis

Question 9

pulmonary embolism ECG findings

Answer 9

S1Q3T3
deep S waves in lead I
deep Q waves in lead III
inverted T waves in lead III

Question 10

management suspected pulmonary embolism

Answer 10

Well’s score:
4 or less = PE unlikely → D-dimer → immediate CTPA + admission if +ve
5 or more = PE likely → admission + immediate CTPA

Question 11

management confirmed pulmonary embolism

Answer 11

1. LMWH (tinzaparin 175units/kg once daily SC) / fondaparinux for > 5 days / until INR > 2 for > 24hrs
   for 6mths for pts w active cancer
2. start warfarin within 24hrs
   continue for at least 3mths and reassess whether should be continued
   continue for >3mths if unprovoked PE
3. thrombolysis for massive PE w haemodynamic instability: tPa, streptokinase

Question 12

management stable COPD

Answer 12

1. short acting bronchodilator: SABA (salb) / SAMA (ipratropium)
2. • long acting bronchodilator: LABA (salmeterol), LAMA (tiotropium)
3. • inhaled corticosteroid (combined inhalers if poss)
     long-term oxygen therapy
     surg: lung volume reduction surg / transplant

Question 13

management acute COPD

Answer 13

ABCDE

1. neb salb / ipratropium
2. oxygen if sats < 90 (aim for 88-92%) via venturi
3. oral steroids 5 days
4. NIV (BiPAP) if respiratory insufficiency
5. antibiotics if infective exacerbation

Question 14

management acute asthma

Answer 14

ABCDE 
oxygen: high-flow 15L via non-rebreathe mask 
neb 5mg salb (oxygen-driven / via spacer) 
oral pred 40mg (5 days) 
neb ipratropium
IV magnesium sulphate 
IV aminophylline 
intubation + ventilation

Question 15

management stable asthma

Answer 15

1. PRN inhaled SABA (salb)
2. • BD inhaled low-dose CS (beclamethasone)
3. • inhaled LABA (salmeterol)
     if not effective consider: increased steroid dose, LTRA (montelukast), SR theophylline, oral beta-agonist
4. daily oral steroids

Question 16

indications for NIV (BiPAP)

Answer 16

COPD w respiratory acidosis 7.25-7.35
type 2 respiratory failure (neuromuscular disease or chest wall deformities)
failure of CPAP for pulmonary oedema

Question 17

indications for CPAP

Answer 17

chronic severe obstructive sleep apnoea

type 1 respiratory failure e.g. acute pulmonary oedema

Question 18

ILD management

Answer 18

cons: MDT approach, smoking cessation, pulmonary rehabilitation
med: anti-fibrotic drugs e.g. pirfenidone, nintedanib
steroids (exacerbation fo Sx)
LTOT
surgery: lung transplant (curative)

Question 19

signs on examination ILD

Answer 19

clubbing

fine end-inspiratory crepitations

Question 20

causes of upper lobe fibrosis

Answer 20

ROTAS:
radiation
occupational: EAA / pneumoconiosis 
TB 
ank spond
sarcoidosis

Question 21

causes of lower lobe fibrosis

Answer 21

DR CIA: 
drugs: methotrexate, amiodarone
connective tissue disease e.g. RA, SLE 
idiopathic pulmonary fibrosis 
asbestos

Question 22

indications for pneumonectomy

Answer 22

primary lung cancer
pulmonary metastases 
traumatic lung injury 
bronchiectasis 
infection: TB, fungal

Question 23

indications for lobectomy

Answer 23

primary lung cancer
lung volume reduction (COPD)
bronchiectasis
infection: TB (upper lobe), fungal

Question 24

differentials for thoracotomy scar

Answer 24

pneumonectomy 
lobectomy 
lung transplant 
chest wall resection 
oesophagectomy

Question 25

indications for lung transplant

Answer 25

``` COPD ILD cystic fibrosis alpha1-antitrypsin deficiency pulmonary HTN bronchiectasis ```

Question 26

differentials for coarse crackles vs fine crackles

Answer 26

corase: bronchiectasis, COPD, pneumonia fine: ILD, pulmonary oedema, pneumonia, atelectasis

Question 27

differentials for wheeze

Answer 27

asthma / COPD bronchiectasis anaphylaxis foreign body

Question 28

signs on examination bronchiectasis

Answer 28

``` clubbing coarse crackles high-pitched inspiratory squeaks monophonic wheeze rhonchi (low-pitched rattling due to secretions in bronchial airways) ```

Question 29

causes of bronchiectasis

Answer 29

idiopathic post-infective: TB, measles, ABPA genetic: a1antitrypsin, cystic fibrosis, Kartagener's bronchial obstruction: malignancy, foreign body, lymphadenopathy connective tissue disease: RA, sjogren's EDS, marfan

Question 30

management bronchiectasis

Answer 30

cons: airway clearance therapy (postural drainage, percussion, vibration) pulmonary rehabilitation med: ABx for acute exacerbations long-term macrolide if >2 / year bronchodilators / theophylline if trial shows improvement LTOT surg: resection of bronchiectatic areas of lung lung transplant

Question 31

investigations bronchiectasis

Answer 31

bedside: sputum culture bloods: FBC, U&Es alpha1 antitrypsin screen for immunodeficiency / connective tissue disease aspergillus markers cystic fibrosis testing imaging: CXR high-res CT is diagnostic (ring shadows, tramlines) other: lung function testing (obstructive)

Question 32

types of lung cancer

Answer 32

non-small cell: squamous cell: PTHrP → Ca adenocarcinoma: non-smokers large cell small cell: ectopic hormone production (ADH, ACTH, PTH, GnRH)

Question 33

presentation pancoasts tumour

Answer 33

apical lung tumour → compression of structures: brachial plexus → hand muscle wasting arteries → oedema of arms sympathetic ganglion → Horner's syn (ptosis, miosis, anhydrosis) SVC → facial swelling / flushing, difficulty breathing small cell tumours → ectopic hormone production (ACTH, ADH, PTH)

Question 34

investigations lung cancer

Answer 34

``` bloods: FBC, U+Es, LFTs, bone profile CXR, contrast CT PET-CT → distant mets bronchoscopy + biopsy lung function testing (?fit for surg) ```

Question 35

complications of old TB

Answer 35

aspergilloma in old TB cavity bronchiectasis (lymph node causes obstruction) risk of bronchial carcinoma

Question 36

causes of consolidation

Answer 36

fluid: pulmonary oedema pus: pneumonia blood: pulmonary haemorrhage cells: malignancy

Question 37

pneumonia severity score + resulting action

Answer 37

confusion urea > 7 resp rate > 30 BP < 90/60 (either systolic OR diastolic) age > 65 1: community management 2: community management if sats > 90 + normal CXR 3: admit 4: consider ITU 5: manage in ITU (30% mortality at 30 days)

Question 38

types of pneumothorax

Answer 38

spontaneous: no precipitating event traumatic: penetrating / blunt chest injury tension: one-way valve → air entry during inspiration (emergency)

Question 39

management pneumothorax

Answer 39

primary: no underlying lung disease < 2cm / no SOB: conservative, discharge w advice + follow-up CXR > 2cm / SOB: aspiration 2nd ICS MCL w large-bore cannula failure → chest drain: 5th ICS MAL ``` secondary: underlying lung disease e.g. asthma, COPD, cystic fibrosis admit for > 24hrs < 1cm: oxygen + analgesia + observation 1-2cm: aspiration >2cm / > 50years: chest drain ```

Question 40

borders of safe triangle (for chest drain)

Answer 40

base of axilla lat border pec major ant border latissimus dorsi 5th ICS / line superior to horizontal level of nipple

Question 41

signs on examination pneumothorax

Answer 41

reduced chest expansion hyperressonance absent / reduced breath sounds + TVF tracheal deviation from affected side in tension pneumothorax

Question 42

management recurrent pleural effusion

Answer 42

recurrent aspiration pleurodesis: insertion of temporary chest drain + talc (sclerosing agent) indwelling pleural catheter opioids relieve dyspnoea

Question 43

management pneumonia

Answer 43

ABCDE oxygen, analgesia, fluids ABx: mild: 5 days oral amox (macrolide if allergic / atypical) mod: 7-10 days oral / IV amox + macrolide severe: IV co-amox + macrolide repeat CXR in 6wks post-resolution

Question 44

mechanism of BiPAP

Answer 44

iPAP > ePAP iPAP: ventilates ePAP: recruits collapsed / underventilated alveoli

Question 45

causes of tracheal deviation

Answer 45

pulls towards: lobar / lung collapse, pneumonectomy, pulmonary hypoplasia pushes away: tension pneumothorax, massive pleural effusion, large thoracic mass, diaphragmatic hernia

Question 46

management of anaphylaxis (incl dose)

Answer 46

``` IM adrenaline 0.5mg 1:1000 IV hydrocortisone 200mg neb salb IV chlorphenamine 10mg + IV fluids if shock ```

Question 47

management hospital acquired pneumonia

Answer 47

< 5 days: co-amox / cefuroxime > 5 days: tazocin / ciprofloxacin pseudomonas: tazocin MRSA: vancomycin

Question 48

causes of ARDS

Answer 48

pulmonary: trauma, pneumonia, inhalation of smoke / soot | extra-pulmonary: sepsis, DIC, pancreatitis