Resp Flashcards
1
Q
Name four features of moderate acute asthma
A
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
2
Q
Name four features of severe acute asthma
A
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
3
Q
Name five features of life threatening acute asthma
A
PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
4
Q
Normal CO2 in acute asthma attack indicates what?
A
Exhaustion
Classify as life threatening
5
Q
What are the three most common causes of acute exacerbation of COPD?
A
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
6
Q
What is management of acute exacerbation of COPD?
A
- Increase frequency of bronchodilator
- 7-14 days of 30mg Prednisolone
- Antibiotics if signs of pneumonia (Amoxicillin or Tetracycline or Clarithromycin)
7
Q
What are the pathogenesis and features of acute respiratory distress syndrome (ARDS)?
A
Increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli.
Criteria:
- Acute onset (<1 weeks of known risk factor)
- Pulmonary oedema (bilateral infiltrates on CXR)
- Non-cardiogenic
- p)2/FiO2 <40kPa
Treatment: Aim for FiO2 below 40%. Add PEEP might help. Maintain low tidal volume ventilation.
8
Q
What are the features and investigation findings of allergic bronchopulmonary aspergillosis?
A
Due to allergy to aspergillus spores. History of bronchiectasis and eosinophilia
Features
bronchoconstriction: wheeze, cough, dyspnoea. ?asthmatic
bronchiectasis (proximal)
Investigations
eosinophilia
flitting CXR changes
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE
9
Q
Management of allergic bronchopulmonary aspergillosis?
A
Steroids
Itraconazole as second line
10
Q
Features of alpha-1 antitrypsin deficiency?
A
Panacinar emphysema
Liver cirrhosis and HCC
11
Q
Management of alpha-1 antitrypsin deficiency?
A
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
12
Q
Management of HACE and HAPE (altitude)?
A
Management of HACE
descent
dexamethasone
Management of HAPE
descent
nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors*
oxygen if available
13
Q
Latent period of asbestos exposure for:
Pleural plaques
Asbestosis
A
Pleural plaques 20-40 years
Asbestosis 15-30 years
14
Q
What bacteria are often implicated in aspiration?
A
The bacteria often implicated in aspiration pneumonia are aerobic, and often include: Streptococcus pneumoniae Staphylococcus aureus Haemophilus influenzae Pseudomonas aeruginosa
Other aerobic, and anaerobic, organisms can also result in aspiration pneumonia, but are less common.
15
Q
Management of acute asthma attack?
A
- Nebuliser Salbutamol and Ipratropium Bromide
- Magnesium Sulphate (1.2-2g IV over 20 mins)
- If no response, consider IV salbutamol
16
Q
Diagnosis of asthma?
A
Age > 17 (all below)
- Symptoms better/worse away from work. If so, refer for occupational asthma
- Spirometry with bronchodilator reversibility test
- FeNO test
Age 5-16
- Spirometry with bronchodilator reversibility test
- FeNO test if normal spirometry or obstructive spirometry with negative BDR test
NOTE:
FeNO >40 positive
Spiro FEV1/FVC ratio <70% is obstructive
Reversibility Improvement FEV1 12% or more and increase in volume of 200ml or more
17
Q
What seven things are associated with occupational asthma? How can you investigate?
A
isocyanates - the most common cause. Example occupations include spray painting and foam moulding using adhesives platinum salts soldering flux resin glutaraldehyde flour epoxy resins proteolytic enzymes
Serial measurements of peak expiratory flow are recommended at work and away from work.
18
Q
What is Berylliosis?
Name two features and two occupational risk factors
A
Occupational lung disease caused by inhalation of fumes of molten beryllium.
Features: Lung fibtosis and bilateral hilar lymphadenopathy
Occupational risk factors:
Aerospace industry
Manufacture of fluorescent light bulbs/golf club heads
19
Q
Name four contraindications to chest drain
A
INR >1.3
Platelet Count <75
Pulmonary Bullae
Pleural Adhesions
20
Q
Name five complications of chest drain insertion
A
Failure of insertion Bleeding Infection Penetration of lung Re-expansion pulmonary oedema
Should not exceed 1L fluid over 6 hours or may cause re-expansion pulmonary oedema
21
Q
When should chest drain be removed for fluid draining or pneumothorax?
A
Fluid: When no output for > 24 hours and resolution of collection on imaging
Pneumothorax: When no longer bubbling spontaneously/when coughs and imaging shows resolution
22
Q
Name 7 causes of bronchiectasis
A
post-infective: tuberculosis, measles, pertussis, pneumonia
cystic fibrosis
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
yellow nail syndrome
23
Q
Most common organisms isolated from bronchiectasis patients?
A
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
24
Q
Management of bronchiectasis?
A
Physical training Postural drainage Antibiotics for exacerbations Long term rotating antibiotics Bronchodilators for some Immunisations
25
What is bronchiolitis? Name five features
Acute bronchiolar inflammation
75-80% caused by RSV
coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
26
Differentials for cavitating lung lesion on CXR? (name 7)
abscess (Staph aureus, Klebsiella and Pseudomonas)
squamous cell lung cancer
tuberculosis
Wegener's granulomatosis
pulmonary embolism
rheumatoid arthritis
aspergillosis, histoplasmosis, coccidioidomycosis
27
Differentials for coin lesions on CXR? Name 4
malignant tumour: lung cancer or metastases
benign tumour: hamartoma
infection: pneumonia, abscess, TB, hydatid cyst
AV malformation
28
Causes of lobar collapse on X-Ray? Name 3
lung cancer (the most common cause in older adults)
asthma (due to mucous plugging)
foreign body
29
Name five cancers that commonly metastases to lung?
Which causes cannonball metastases?
```
breast cancer
colorectal cancer
renal cell cancer
bladder cancer
prostate cancer
```
Cannonball metastases commonly renal
30
Causes of lung white out as by trachea deviation (pulled towards, central, pushed away)
Pulled Toward:
Pneumonectomy
Complete lung collapse
Pulmonary Hypoplasia
Central:
Consolidation
Pulmonary oedema
Mesothelioma
Pushed Away:
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
31
Name five causes of COPD
Smoking!
Alpha-1 antitrypsin deficiency
```
Other causes
cadmium (used in smelting)
coal
cotton
cement
grain
```
32
How is COPD diagnosed and then categorised?
Post-bronchodilator FEV1/FVC <0.7
Mild >80% FEV1
Moderate 50-79%
Severe 30-49%
Very Severe <30%
33
Investigations for COPD?
Post bronchodilator spirometry
CXR
FBC
BMI
34
Who qualifies for LTOT in COPD? Who to assess and how?
What is the minimum time it must be used per day?
Assess if FEV1<30%, cyanosis, polycythaemia, perioheral oedema, raised JVP, O2 <92%
Assess with ABG 2x at least 3 weeks apart
```
Offer if pO2 <7.3kPa
Offer if pO2 7.3-8kPa and
secondary polycythaemia
peripheral oedema
pulmonary HTN
```
Do not offer if continue to smoke
15 hours per day (including night time)
35
What are the 7 steps of asthma management?
1. SABA
2. SABA + ICS (low)
3. SABA + ICS (low) + LRTA
4. Continue LRTA if effective. SABA + ICS (low) + LABA
5. SABA +/- LRTA + MART (low)
6. SABA +/- LRTA + MART (medium)
7. SABA +/- LRTA + high dose ICS + LABA
Steroid
Low dose <400
Moderate 400-800
High >800
36
What are the steps for COPD stable management?
```
General:
Smoking cessation
Annual influenza vaccination
One off pneumococcal vaccination
Pulmonary rehab if functionally disabled
```
Medical:
1. SABA or SAMA
Not steroid responsive:
2. LABA + LAMA (+ SABA)
If steroid responsive (previous asthma/atopy, high eosinophils, substantial variation in FEV1 (>400ml), substantial diurnal variation in peak flow (at least 20%))
2. LABA + ICS (+SABA/SAMA)
3. LAMA + LABA + ICS + SABA
Oral theophylline - only after trials of short and long-acting bronchodilators. Reduce if macrolide co-prescribed
Prophylactic antibiotics:
Azithromycin (if optimal medical therapy and continue to have exacerbation)
Mucolytics: If chronic productive cough
Cor Pulmonale:
Loop diuretic +/- LTOT
37
Management of cystic fibrosis?
1. BD Chest Physio and postural drainage
2. High calorie diet
3. Avoid contact with other CF
4. Vitamin supplementation
5. Pancreatic enzyme supplements
6. Lumacaftor/Ivacaftor (Orkambi) - if homozygous for dF508 mutation
38
Features of eGPA
Churg Strauss
Small-medium vessel vasculitis
```
asthma
blood eosinophilia (e.g. > 10%)
paranasal sinusitis
mononeuritis multiplex
pANCA positive in 60%
```
eGPA associated with Leukotriene Receptor antagonists
Three Phases:
1. Atopy (asthma, rhinitis, sinusitis), 2. Eosinophilia >10% (pulmonary infiltrates), 3. Necrotizing multi-system small vessel vasculitis (rash, peripheral neuropathy, renal involvement - RPGN)
39
Features of extrinsic allergic alveolitis (aka Hypersensitivity Pneumonitis)
immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.
Bird fanciers lung (avian protein)
Farmers lung (spores of Saccharopolyspora rectivirgula)
Malt workers lung (aspergillus clavatus)
Mushroom workers lung (terhmophilic actinomycetes)
Presentation
acute: occur 4-8 hrs after exposure, SOB, dry cough, fever
chronic
Patients well between episodes
Investigation
chest x-ray: upper/mid-zone fibrosis
bronchoalveolar lavage: lymphocytosis - eosinophilia
blood: NO eosinophilia
Acute neutrophilic inflammation followed by lymphocytic infiltration and colllagen deposition
40
Features of GPA?
Wegner's Granulomatosis
Features
upper respiratory tract: epistaxis, sinusitis, nasal crusting
lower respiratory tract: dyspnoea, haemoptysis, cavitating lung lesions
rapidly progressive glomerulonephritis ('pauci-immune', 80% of patients)
saddle-shape nose deformity
also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions
Investigations
cANCA positive in > 90%, pANCA positive in 25%
chest x-ray: wide variety of presentations, including cavitating lesions
renal biopsy: epithelial crescents in Bowman's capsule
41
Management of GPA
steroids (methylprednisolone)
cyclophosphamide (90% response)
plasma exchange
median survival = 8-9 years
42
Features, investigation and management of idiopathic pulmonary fibrosis? What is life expectancy?
```
Features
progressive exertional dyspnoea
bibasal fine end-inspiratory crepitations on auscultation
dry cough
clubbing
```
```
Diagnosis:
Spirometry - restrictive
TCLO reduced
Bilateral interstitial shadowing (ground glass --> honeycombing)
ANA positive 30%
RF positive 10%
CXR - reticulonodular shadowing
```
Management:
Pulmonary rehabilitation
Pirfenidone
Supplemental O2
Life expectancy 4 years
43
Features of klebsiella pneumonia? Four things
more common in alcoholic and diabetics
may occur following aspiration
'red-currant jelly' sputum
often affects upper lobe
44
What is Lofgren's Syndrome? What four features should I be aware of?
```
acute form sarcoidosis
bilateral hilar lymphadenopathy (BHL)
erythema nodosum,
fever
polyarthralgia.
```
More common in scandanavians
Good prognisis
45
Paraneoplastic syndromes from small cell lung cancer (3)
ADH
ACTH
Lambert-Eaton Syndrome
N.B. Usually centally located
46
Paraneoplastic syndromes from squamous cell lung cancer (3)
PTH-rp
Hypertrophic pulmonary osteoarthropathy
Ectopic TSH
NOTE: Also clubbing present
47
Paraneoplastic syndromes from adenocarcinoma lung cancer (1)
Hypertrophic pulmonary osteoarhropathy
NOTE: Gynaecomastia also present
48
For which lung cancer is PET scanning considered?
Non-small cell lung cancer
To establish eligibility for curative treatment
49
What is the management of Non-small cell lung cancer?
1. Lobectomy if Stage 1, 2. Curative intent
NOTE: Perform mediastinoscopy prior to surgery for ?mediastinal lymph nodes
2. Radiotherapy if Stage 1, 2, 3. Curative intent
3. Chemotherapy if Stage 3, 4. Improve survival and QoL
N.B.
Adjuvant chemotherapy if complete resection
Adjuvant radiotherapy if incomplete resection
Consider chemoradiotherapy for all stage 1-3 if not suitable for surgery
50
What is the management of small cell lung cancer?
1. Surgery ONLY if very early Stage 1 or 2
Limited Stage T1-4, N0-3, M0
Cisplatin combination chemotherapy
Adjuvant radiotherapy only if good response to chemo
Extensive Stage M1
Platinum based chemotherapy
Adjuvant radiotherapy only if good response to chemo at both primary and metastasis
Relapse after initial treatment
Further Chemo
Palliative radiotherapy
51
Contraindications for surgery in non-small cell lung cancer?
assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
* if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on the results
52
Causes of upper zone lung fibrosis (7)
hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis)
coal worker's pneumoconiosis/progressive massive fibrosis
silicosis
sarcoidosis
ankylosing spondylitis (rare)
histiocytosis
tuberculosis
```
CHARTS
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
```
53
Causes of lower zone lung fibrosis (4)
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
54
How to investigate suspected mesothelioma?
CXR
Pleural CT
If effusion, MC&S, biochemistry, cytology
Local anaesthetic thorascopy if negative effusion sample
Pleural nodularity on CT --> Image guidd pleural biopsy
55
Features of microscopic polyangitis?
```
Renal impairment
Fever
Palpable Purpura
Cough/ SOB/Haemoptysis
Diffuse alveolar haemorrhage
Mononeuritis Multiplex
Lethargy/Myalgia/Weight Loss
```
NOTE: Spares the URT
pANCA (against MPO) - positive in 50-75%
cANCA (against PR3) - positive in 40%
56
Where is MERS from and what is it caused by?
Middle East respiratory syndrome (MERS) is caused by the betacoronavirus MERS-CoV.
Arabian Peninsula
2-14 day incubation period
Lymphocytopenia
Thrombocytopenia
Derranged LFTs
57
Indications for non-invasive ventilation? (4)
COPD respiratory acidosis pH 7.25-35
Type 2 resp failure due to chest wall deformity, neuromuscular disease or OSAS
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation
58
Three main disease types for non-tuberculous mycobacteria?
Hypersensitivity like disease
Cavitating disease
Bronchiectasis with or without nodules
59
Features and management of obesity hypoventilation syndrome?
```
Morning headaches
Daytime sleepiness
Reduced exercise tolerance
Poor concentration
Day time hypercapnia
```
Management:
Weight loss
Assisted ventilation
Supplemental oxygen
60
Assessment and diagnostic tests for OSAS
Epworth Sleepiness Scale
Multiple Sleep Latency Test (how long to fall asleep in dark room)
```
Diagnostic Test:
Sleep studies (polysomnography)
```
NOTE: Over long periods of time: CO2 compensated by renal retention of bicarbonate. Become CO2 retainers.
61
Management of OSAS?
Weight loss
CPAP
Intra-oral device if CPAP not tolerated OR mild OSAS with no daytime sleepiness
Should inform DVLA if excessive day time sleepiness
62
Causes of pleural transudate? What is the protein level?
(< 30g/L protein)
heart failure (most common transudate cause)
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
hypothyroidism
Meigs' syndrome
63
Causes of pleural exudate? What is the protein level?
```
(> 30g/L protein)
infection: pneumonia (most common exudate cause), TB, subphrenic abscess
connective tissue disease: RA, SLE
neoplasia: lung cancer, mesothelioma, metastases
pancreatitis
pulmonary embolism
Dressler's syndrome
yellow nail syndrome
```
64
What is lights criteria and when is it used?
To distinguish between transudate and exudate if protein level 5-35g
Exudate if:
pleural fluid protein divided by serum protein >0.5
pleural fluid LDH divided by serum LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
65
What does low glucose in pleural fluid suggest?
rheumatoid arthritis, tuberculosis
66
What does raised amylase in pleural fluid suggest?
pancreatitis, oesophageal perforation
67
What does heavy blood staining in pleural fluid suggest?
mesothelioma, pulmonary embolism, tuberculosis
68
When would you suspect a pleural infection with a pleural effusion that requires chest drain insertion?
Fluid purulent or turbid
| Clear fluid but pH <7.2 with suspected pleural infection
69
Features of mycoplasma pneumoniae?
Dry cough
Atypical CXR
AIHA
Erythema Multifrome
70
Features of legionella pneumophilia?
Hyponatraemia
Lymphopenia
Classically secondary to infected air conditioning
71
Components of CURB 65 score?
```
Confusion (AMTS 8 or less)
Urea > 7
RR > 30
BP < 90 sys, <60 dys
Age 65+
```
72
What to do with CURB 65 score of:
0
1
2
0 - manage community
1 - if sats >92%, manage in community and CXR. If bilateral/multilobar shadow, admit
2+ - admit
73
What are the risks associated with CURB 65 score?
0 -1 - Low risk <3% mortality
2+ - intermediate risk 3-15% mortality
3+ - high risk 15% mortality
74
When should you not discharge following a pneumonia?
If two or more in the past 24 hours
```
Temp 37.5 +
RR 24 +
HR 100+
BP <90
O2<90
Abnormal mental state
Can't eat
```
75
Management of pneumothorax in Primary cases
<2cm and no SOB - consider discharge
Otherwise aspirate
If fails (remains >2cm or SOB), chest drain
76
Management of secondary pneumothorax?
If 50+ and >2cm and/or patient SOB - chest drain
Otherwise, if 1-2cm - aspirate. If fails (remains >1cm) - chest drain
If <1cm, give O2 and admit for 24 hours
(NOTE: 2cm = 50% pneumothorax)
77
Causes of pulmonary eosinophilia? (8)
```
Churg-Strauss syndrome
allergic bronchopulmonary aspergillosis (ABPA)
Loffler's syndrome
eosinophilic pneumonia
hypereosinophilic syndrome
tropical pulmonary eosinophilia
drugs: nitrofurantoin, sulphonamides, ampicillin, NSAIDs, minocycline
less common: Wegener's granulomatosis
```
78
Cause of tropical pulmonary eosinophilia?
Wuchereria bancrofti/Brugia malayi infection
History of paroxysmal nocturnal cough
Wheeze
SOB
Diagnosis aided by clinical response to Diethylcarbamazine
Spread by mosquito
Mature in the lymphatics
Can cause elephantiasis
79
What is Loffler's syndrome? Can you name some features?
Transient CXR shadow
Blood eosinophilia
Ascaris lumbricoides/strongyloides/ancylostoma causing an alveolar reaction
Fever, cough, night sweats
Self limiting (2 week)
Can treat with Mebendazole for 3 days
80
Can you classify the five types of pulmonary hypertension?
Pulmonary arterial hypertension - idiopathic
(familial, collagen disorder, cogenital heart disease with systemic shunts, drugs and toxins, persistent pulmonary HTN of newborn)
Pulmonary hypertension with left heart disease
(LV systolic and diastolic dysfunction, mitral stenosis, mitral regurgitation)
Pulmonary HTN secondary to lung disease/hypoxia
(COPD, ILD, OSAS, altitude)
Pulmonary HTN due to thromboembolic disease
Miscellaneous conditions
(lymphangiomatosis)
81
What are the Centor criteria?
presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
absence of cough
82
What are the respiratory manifestations of rheumatoid arthritis?
pulmonary fibrosis
pleural effusion
pulmonary nodules
bronchiolitis obliterans
complications of drug therapy e.g. methotrexate pneumonitis
pleurisy
Caplan's syndrome - massive fibrotic nodules with occupational coal dust exposure
infection (possibly atypical) secondary to immunosuppression
83
Name three syndromes associated with Sarcoidosis
Lofgren's syndrome - BHL, erythema nodosum, fever, polyarthralgia (good prognosis)
Mikulicz Syndrome - elnargement of parotid and lacrimal glands (sarcoid, TB or lymphoma)
Heerfordt's Syndrome (uveoparotid fever) - parotid enlargement, fever, uveitis
84
Features associated with sarcoidosis?
```
Acute:
Erythema nodosum
BHL
Swinging fever
Polyarthralgia
```
```
Insidious:
SOB
Non-productive cough
Malaise
Weight Loss
```
Skin:
Lupus pernio
Hypercalcaemia
85
Features of sarcoidosis and staging on chest x-ray?
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
86
Sarcoidosis spirometry and tissue biopsy results?
Use of ACE levels?
spirometry: may show a restrictive defect
tissue biopsy: non-caseating granulomas
ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not reliable in the diagnosis of sarcoidosis although they may have a role in monitoring disease activity.
87
Management of sarcoidosis?
Steroids if:
CXR - stage 2 or 3 with symptoms
Hypercalcaemia
Eye, heart or neuro involvement
88
Occupations at risk of silicosis? Features?
Mining
Slate works
Foundries
Potteries
Features:
Fibrosing lung disease
Egg shell calcification of hilar lymph nodes
89
Whos the coolest F2 I know? / Whos Milkshake Brings all the boys to the yard? / Who will bring balance to the force?
Dr Olli Sharp BMBS BSc
90
What is the air speed velocity of an unladen swallow
African or European?
91
What three options for smoking cessation are there?
Nicotine replacement therapy
Varenicline
Bupropion
Do not favour one over another. Do not combine
Prescribe for only 2 weeks after stop date for NRT, 3-4 weeks for the other two
If fail, do not represcribe within 6 months
92
Adverse effects of nicotine replacement therapy?
N&V
Headache
Flu like symptoms
93
Adverse effects of Varenicline?
Contraindication?
Start one week before stop date. 12 week course
Nausea
Headache
Insomnia
Abnormal dreans
Contraindication
Depression/self harm (relative)
Pregnancy
Breast feeding
94
Adverse effects of Varenicline?
Contraindication?
1-2 weeks before stop date
```
Contraindication
Epilepsy
Pregnancy
Breast feeding
Eating disorder (relative)
```
NOTE: Small risk of seizure
95
Smoking cessation in pregnant women?
All should be tested
1. CBT, Motivational interview, structured self help
2. Nicotine replacement therapy if fails
the other varenicline and bupropion are contraindicated
96
What are the guidelines for monitoring lung nodules?
< 5mm and benign - discharge
5-6mm or => 8mm and low risk - CT surveillance
=> 8mm and high risk - CT PET. If abnormal, biopsy
CT 5-6mm - at one year
CT =>6 - three months
97
Features and management of theophylline poisoning?
```
Features:
Acidosis, Hypokalaemia
Vomiting
Tachycardia, arrhythmia
Seizure
```
Management:
Gastric lavage
Activated charcoal
Seizures controlled by benzodiazepines or intubation
98
Causes of raised TLCO? (6)
```
asthma
pulmonary haemorrhage (Wegener's, Goodpasture's)
left-to-right cardiac shunts
polycythaemia
hyperkinetic states
male gender, exercise
```
99
Causes of low TLCO? (7)
```
Restrictive lung disease
• Idiopathic pulmonary fibrosis
• Occupational lung disease
• Hypersensitivity pneumonitis
• Miliary tuberculosis
• Pneumonectomy
```
Obstructive lung disease
• Cystic fibrosis
• Emphysema
Other causes
• Chronic pulmonary embolism
• Congestive heart failure (pulmonary oedema, low cardiac output)
• Primary pulmonary hypertension
Anaemia
100
Sites of secondary TB?
```
central nervous system (tuberculous meningitis - the most serious complication)
vertebral bodies (Pott's disease)
cervical lymph nodes (scrofuloderma)
renal
gastrointestinal tract
```
101
Management of latent TB? Two options...
NICE now give two choices for treating latent tuberculosis:
3 months of isoniazid (with pyridoxine) and rifampicin
6 months of isoniazid (with pyridoxine)
102
What is thunderstorm asthma?
Sudden spore and pollen release due to pressure change resulting in asthma attack
103
What levels of pressure should BiPAP be started on?
IPAP 15
EPAP 3
If pH <7.25 IPAP 20
Neuromuscular disease start with IPAP 10
104
Complications of NIV?
Breathing against machine (dyssynchrony)
Aspiration (vomiting/secretions) --> Mucous Plug
Pneumothorax
Ventilator associated pneumonia
105
In a patient with acute exacerbation of COPD with Type respiratory failure and acidosis, when should NIV be considered?
Failure of optimal medical therapy meaning hypercapnia and acidosis do not improve
The NIV
If fails to improve, for consideration of invasive ventilation
106
What can be used in COPD exacerbations when NIV is unavailable or inappropriate?
Respiratory Stimulants (doxapram)
107
Contraindications to NIV? (7)
Recent facial/upper airway surgery or injury
Recent UGI surgery
Confusion/agitation
Bowel obstruction
Upper airway obstruction
Excessive upper airway secreitions
Acute vomiting
108
Should nebulisers with NIV be given together or should the mask be taken off to administer nebuliser?
Take off mask to administer nebuliser
| increased efficacy
109
Features and management of eosinophilic pneumonia?
Sub-acute respiratory symptoms
Alveolar/blood eosinophilia
Peripheral pulmonary infiltrates on imaging
Treat with oral corticosteroids
Good prognosis
110
When is Roflumilast used?
Already on maximal medical therapy
Recommended in COPD where =>2 exeracerbations per year and FEV1 <50%
Phosphodiesterase-4 inhibitor
111
Fun fact!
Silicosis increases susceptibility to TB
112
Most common cause of cannon ball metastases?
Renal cell cancer
113
Name two common scenarios in which CPAP is used?
OSAS
| Pulmonary Oedema
114
What is Mepolizumab? When is it used?
IL-5 antagonist (monoclonal antibody)
Treatment of severe eosinophilia
resistant asthma
115
What is omalizumab? When is it used?
Treatment of allergic asthma with significant elevation in IgE
Add on therapy for step four.
116
What might you give for symptomatic relief of SOB in end stage COPD?
Opioids
+/- Benzodiazepines
Renal Failure: Alfentanil
117
What is the significance of nasal polyps in asthma?
More likely to have an adverse reaction to NSAIDs
118
What is the time lag for complications following asbestos exposure?
Is compensation possible?
10 Years - pleural plaque
20 Years - asbestosis
30 Years - Mesothelioma
NOTE: Clubbing is associated with progression to mesothelioma
Compensation for asbestosis or mesothelioma from Department of Social Security or Civil Law Claim
119
What is hypertrophic pulmonary osteoarthropathy and how does it present?
Intermittent aching and swelling in wrists and ankles (squamous cell lung cancer)
120
What are the investigation findings for invasive aspergillosis?
How is it treated?
Classical halo sign on CT
Hyphae on silver staining
Mortality 40-90%
1. Voriconazole (IV)
2. Lipsomal Amphotericin
121
What is re-expansion pulmonary oedema?
When does it occur?
Life threatening condition. Following chest drain insertion. Large volume or air is rapidly drained
Sudden onset SOB
Cough
Hypoxaemia
122
Where is histoplasma endemic?
What is the treatment?
What are the features?
Mississippi River Valley
Mild: Itraconazole
Severe: Admit, IV Amphotericin B
Signs: Fevers, mildly elevated WBC, nodular shadow on CXR, urine and serum antigen positive
May present many years down the line
123
What does raised Beta-D-glucan suggest?
Suggests fungal infection
124
Investigations in Pulmonary hypertension. What can you use?
RIght Heart Catheterisation - assess pulmonary pressures
Left Heart Catheterisation - assess coronary arteries
6 minute walk test - assess prognosis
125
SOB following TIPS. What possible complication has occurred?
Pulmonary Hypertension
- due to increased cardiac preload -
126
If during the LTOT assessment in COPD patient, the PaCO2 has risen >1kPa, what should you do?
May have clinically unstable disease
Further medical optimisation
Re-assess at 4 weeks
127
Differential for Bilateral hilar lymphadenopathy?
```
Sarcpodpsos
TB
Malignancy
Cystic Fibrosis
eGPA
HIV
EEA
Phenytoin
Pneumoconioses (berylliosis)
```
128
How should you investigate for TB in HIV patients with CD4 <200?
IFN-gamma
Mantoux
Both should be done. If positive, clinical assessment to exclude active TB.
129
What is non-tuberculous mycobacteria (NTM)? What are common managements?
Presentation:
Hypersensitivity disease
Cavitating disease
Bronchiectasis
Radiology: Cavities, bronchiectasis, nodules
Microbiology: 2 or more positive sputum samples on separate days
Mycobacterium Avium Complex (MAC) - Rifampicin, Clarithromycin, ethambutol (until sputum culture negative for 12 months)
M. Kansaii: Rifampicin, isoniazid, ethambutol (until sputum culture negative for 12 months)
130
What is the treatment of narcolepsy?
Methylphenidate
131
Nintedanib?Pirfenidone?
What are they used for?
Small molecule tyrosine kinase inhibitor inhibitor
Treatment of idiopathic pulmonary fibrosis
Use when:
FVC 50-80% predicted
Treatment is stopped if disease progression in any 12 month period
132
Name some drugs which can cause chronic cough?
```
ACEi
Smoking
Statins
Amiodarone
ARBs
IFN-alpha
IFN-beta
```
133
What is combined pulmonary fibrosis and emphysema (CPFE)?
Higher rates of lung cancer and risk of pulmonary arterial hypertension
```
Features:
Exertional SOB
Uppler Lobe Emphysema
Lower lobe fibrosis
Preserved lung volume
Reduced capacity gas exchange
```
134
What is subglottic stenosis and how can it occur (3)?
Congenital
Idiopathic
Post-intubation
Consider if obstructive picture
135
What is chylothorax? What is it high in?
Accumulation of lymph in pleural space
High in triglycerides
and chylomicrons
136
What is a pseudochylothorax high in? When does it occur
Cholesterol
| Occurs with longstanding fibrotic pleura
137
What drugs can cause pleural effusion?
Nitrofurantoin
MTX
Amiodarone
138
How should you investigate for TB? What is the best type?
Multiple samples (3 deep cough sputum samples) for microscopy and culture
If not possible, induction of sputum or bronchoscopy and lavage
Bronchoscopy - best specimen
Mantoux and IFN-gamma for latent TB
139
What does a high KCO but low DLCO imply for a patient with restrictive lung disease?
It is an extra-pulmonary cause
140
What is lymphangioleiomyomatosis?
Affects premenopausal women
Proliferation of smooth muscle cells in lungs, lymphatics and uterus
Likely caused by oestrogens
Association with Tuberous Sclerosis and renal angiomyolpomas
Symptoms:
SOB
Pneumothorax
Chylous pleural effusion
Management:
Medroxyprogesterone (anti-oestrogen)
141
What is atypical langerhans cell histiocytosis?
```
Affects smokers (age 20-40)
SOB
Cough
Spontaneous Pneuomthorax
Clubbing
Granuloma infiltration in bones and hypothalamus
```
142
Symptoms and signs of Primary ciliary dyskinesia?
```
Autosomal recessive
Sinusitis
Otitis media
Male infertility
Recurrent respiratory infections
40-50% situs inversus
```
143
What is chronic eosinophilic pneumonia
SOB
Fever
Weight Loss
Skin, liver and spleen involvement
Atopic history - sinusitis, rhinitis, angioedema
Extensive dense peripheral infiltrates on CXR
144
What are the modified acute eosinophilic penumonia Philit Criteria?
* acute respiratory illness of less than or equal to 1-month duration
* pulmonary infiltrates on chest radiography or computed tomography (CT)
* pulmonary eosinophilia as demonstrated by more than 25% eosinophils in BAL fluid (can be accompanied by variably increased percentages of lymphocytes and neutrophils) or eosinophilic pneumonia on lung biopsy (bronchoscopic or surgical), and
* the absence of other specific pulmonary eosinophilic diseases e.g. eosinophilic granulomatosis with polyangiitis (previously known as Churg-Strauss syndrome)
145
What is the Kveim Test? What is it used for?
Part of spleen from patient with known sarcoidosis is injected under the skin
No longer used due to converns of cross infection
146
What is the bulging fissure sign and what is it seen in?
Classical feature of klebsiella pneumonia
Due to large volumes of consolidation (typically RUL) causing displacement of adjacent fissure
147
Rusty coloured sputum and proceeding herpes labialis?
Streptococcal pneumoniae
148
Proceeding flu like illness with subsequent rapid deterioration into a bacterial pneumonia?
Staphylococcus aureus
149
What is treatment for infected bronchiectasis?
Oral Ciprofloxacin 14 days
Failure of this: IV Tazocin, Ceftazidime, aztreonam, meropenem
150
Name two common pathogens in cystic fibrosis. Which has worse prognosis?
```
Pseudomonas
Burkholderia (worse prognosis)
```
151
If draining a pneumothorax, at 3-5 days there is still an air leak/failure to re-expand, what should you do?
Thoracic surgical opinion
152
Which emphysema patients benefit from lung volume reduction surgery?
1. UL emphysema and low exercise capacity (improved function and survival)
2. UL and high exercise capacity (improved function, no difference survival)
3. Non-UL and low exercise capacity
The following will not do well and have high risk of death:
- Non-UL and high exercise capacity
- Poor pulmonary function and homogenous emphysema distribution or poor CO diffusing capacity
153
Possible options for treatment to eradicate pseudomonas aeruginosa in CF patients?
IV anti-pseudomonal abx + inhaled aminoglycoside 14 days
Oral ciprofloxacin (6 weeks)
