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Resp Vivas Flashcards

1
Q

Respiratory indications for midline sternotomy

A

Anterior mediastinum tumour resection
Lower trachea + main stem bronchus surgery

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2
Q

What is CREST syndrome?

A

Subtype of limited systemic sclerosis a/w anti-centromere Abs
Calcinosis
Raynaud’s phenomenon
Oesophageal dysmotility
Sclerodactyly
Telangiectasia

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3
Q

Give a differential for CREST syndrome?

A

Diffuse cutaneous systemic sclerosis (anti-scl 70 abs)
(most common cause of death is ILD + pulmonary HTN)

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4
Q

Describe management of COPD

A
  1. SABA or SAMA
  2. Is there steroid responsiveness/ asthmatic features?
    Y: SAMA/ SABA + LABA + ICS
    N: SABA + LAMA + LABA
  3. SABA + LABA + LAMA + ICS
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5
Q

Name a SABA used in COPD

A

Salbutamol

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6
Q

Name a SAMA used in COPD

A

Ipratropium

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7
Q

Name a LAMA used in COPD

A

Tiotropium

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8
Q

Name a LABA used in COPD

A

Salmeterol

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9
Q

Name a ICS used in COPD

A

Budesonide
Beclometasone

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10
Q

Conservative Mx of COPD

A

SMOKING cessation advice: inc. offering NRT: varenicline or bupropion
Annual influenza vaccination
One-off pneumococcal vaccination
Pulmonary rehab to all who view themselves as functionally disabled by COPD

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11
Q

Which 4 features suggest steroid responsiveness in COPD?

A

Previous dx of Asthma or Atopy
High blood eosinophil count
Substantial variation in FEV1 over time (>,400ml)
Substantial diurnal variation in PEF (>,20%)

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12
Q

When can oral theophylline be used in COPD?

A

After trials of short + long-acting bronchodilators or to people who can’t used inhaled therapy

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13
Q

When should mucolytics be considered in COPD?

A

In those with chronic productive cough
Continued if Sx improve

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14
Q

What can be used as prophylactic antibiotic therapy in COPD? When is this indicated?

A

Azithromycin
Continue to have exacerbations despite not smoking + having optimised standard Tx

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15
Q

What prerequisites are there for Azithromycin prophylaxis in COPD?

A

CT thorax (to r/o bronchiectasis)
Sputum culture (to r/o atypical infections + TB)
LFTs + ECG to r/o QT prolongation (as azithromycin can prolong QT)

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16
Q

What can be used to reduce risk of COPD exacerbations in those with severe COPD and frequent exacerbations?

A

PDE-4 inhibitors e.g. Roflumilast

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17
Q

What are the features of cor pulmonale seen in COPD?

A

Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud P2

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18
Q

Describe management of cor pulmonale in COPD

A

LTOT
Loop diuretic for oedema e.g. Furosemide

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19
Q

Which factors may improve survival in patients with stable COPD?

A

Smoking cessation: single most important intervention
LTOT in those who fit criteria
Lung volume reduction surgery in selected patients

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20
Q

What are the types of lung volume reduction?

A

Lung volume reduction surgery
Endobronchial valves

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21
Q

What is lung volume reduction surgery?

A

Worst affected part of lung stapled off + removed. Remaining lung re-inflates + can work more effectively.
Laparoscopic

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22
Q

What are endobronchial valves?

A

Bronchoscopic lung volume reduction (BLVR)
One-way valves stop air from getting into diseased parts of lungs when breathing in but allow air + mucus out when breathing out.
Causes target area of lung to shrink

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23
Q

What are the indications for LTOT?

A

pO2 of < 7.3 kPa OR pO2 of 7.3-8 kPa + one of the following:
secondary polycythaemia
peripheral oedema
pulmonary HTN

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24
Q

Most common cause of infective exacerbation of COPD

A

Haemophilus influenzae

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25
Acute exacerbation of COPD Mx
Increase freq. bronchodilator use +/- give via nebuliser Prednisolone 30mg OD for 5 days If sputum purulent/ clinical signs of pneumonia: Amoxicillin/ Clarithromycin or doxycycline.
26
Criteria for admission in acute exacerbation of COPD
Severe breathlessness Acute confusion/ impaired consciousness Cyanosis O2 sats <90% on pulse ox Inability to cope at home/ living alone Significant comorbidity (cardiac disease or insulin-dependent diabetes)
27
Severe acute exacerbation of COPD Mx
28% Venturi mask, 4 L/min Aim for sats of 88-92% for patients with RFs for hypercapnia + no prior hx of resp. acidosis Target 94-98% if pCO2 is normal Nebulised Salbutamol + Ipratropium Steroids: Pred PO or IV Hydrocortisone IV theophylline If not responding to nebs
28
Describe Mx of T2 respiratory failure in COPD
NIV if resp acidosis pH 7.25-7.35 - BiPaP
29
Interstitial lung disease pathogenesis
Scarring (pulmonary fibrosis), inflammation or a mix
30
What are the exposure related causes of ILD?
Hypersensitivity pneumonitis: farmers lung, bird fanciers lung Pneumoconiosis: Asbestosis, Silicosis, Coal workers lung Radiation pneumonitis Drug induced: Amiodarone, Methotrexate, Nitrofurantoin, Bleomycin
31
What are the causes of ILD secondary to connective tissue disease?
Systemic sclerosis RhA Polymyositis SLE Sjogrens Mixed connective tissue disease
32
Idiopathic causes of ILD
Idiopathic pulmonary fibrosis Cryptogenic organising pneumonitits Non specific interstitial pneumonitis Acute interstitial pneumonitis
33
5 other causes of ILD
Sarcoidosis Vasculitis UC Renal tubular acidosis AI thyroid disease Infections e.g. TB
34
Ix for ILD
Bedside: ABG (resp failure), ECG (right heart strain) Lab: FBC (anaemia, polycythaemia), AI screen, serum ACE (sarcoidosis) Imaging: CXR HRCT: GS Ground glass/ honeycombing Volume loss Bilateral reticulonodular interstitial infiltrates
35
Describe lung function tests in ILD
Restrictive pattern with reduced transfer factor
36
S/S of IPF
Progressive exertion dyspnoea Bibasal fine end inspiratory crepitations Dry cough Clubbing
37
Ix for IPF
Spirometry: restrictive Impaired gas exchange: reduced TLCO CXR: bilateral interstitial shadowing, ground glass, honeycombing HRCT: required for dx
38
Mx of IPF
Conservative: pulmonary rehab Medical: little evidence. Some for Pirfenidone. O2 therapy Surgical: lung transplant
39
4 pulmonary manifestations of sarcoidosis
BHL Dry cough Progressive dyspnoea Reduced exercise tolerance
40
Indications for steroids in sarcoidosis
CXR stage 2/3 + symptomatic (BHL + interstitial infiltrates)
41
Ddx for coarse crackles
Bronchiectasis (may partially clear after coughing) Chronic bronchitis
42
ddx for fine crackles
Pulmonary fibrosis (interstitial process)
43
Lateral thoracotomy scar ddx
Lobectomy (Lung malignancy, localised bronchiectasis, Aspergilloma, Large bullectomy (COPD)) Pneumonectomy (malignancy) Single lung transplant Lung volume reduction surgery
44
Describe examination findings in pneumonectomy
Left/ right thoracotomy scar Dull percussion note Absent breath sounds Trachea deviation towards pneumonectomy Reduced expansion
45
Describe examination findings in lobectomy
Left/ right thoracotomy scar May be no other signs due to compensatory hyperexpansion of remaining lobes May be some reduced expansion, dullness to percussion + reduced air entry
46
Describe CXR of lobectomy/ pneumonectomy
FLUID fills cavity of removed lung (radio-OPAQUE) Organs shift into cavity of removed lung (i.e. heart + trachea displaced)
47
Define bronchiectasis
Permanent dilation of air wards secondary to chronic infection or inflammation
48
5 causes of bronchiectasis
Post infective: TB, measles, pertussis, pneumonia CF Allergic bronchopulmonary aspergillosis Immune deficiency: selective IgA Ciliary dyskinetic function: Kartageners syndrome
49
5 S/S of bronchiectasis
Persistent PRODUCTIVE cough Dyspnoea Haemoptysis Coarse crackles + wheeze Clubbing
50
Ix for bronchiectasis
Sputum culture Spirometry FBC inc. WCC CXR: r/o other pathology HRCT: GS- signet ring sign, tram tracking, ring shadows, volume loss
51
Mx of bronchiectasis
Physical training: inspiratory muscle training Postural drainage Abx for exacerbations Bronchodilators in some Immunisations Surgery in localised disease
52
Most common organism isolated from those with bronchiectasis
H influenzae
53
Pathogenesis of CF
Increased viscosity of secretions due to defect in CF transmembrane conductance regular gene Delta F508 on Chr7 Autosomal recessive
54
How may CF present?
Neonatal: meconium ileus Recurrent chest infections Malabsorption: steatorrhoea, FTT Liver disease
55
6 features of CF
Short DM Delayed puberty Rectal prolapse Nasal polyps Infertility/ subfertility
56
Ix for CF
Heel prick test (newborn screening) Sweat test: abnormally high sweat chloride Genetic test: blood/ saliva
57
Mx of CF
MDT approach BD chest PT + postural drainage High calorie diet inc. high fat Minimise contact with other CF Vitamin supplementation Pancreatic enzyme supplementation Lung transplant
58
CI to lung transplant in CF
Burkholderia cepacia
59
What drug may be used in CF?
Lumacaftor/ Ivacaftor (Orkambi)
60
Causes of pulmonary oedema
Cardio: LVF (post MI/ IHD), valvular ARDS: ?predisposing factors e.g. trauma, sepsis Fluid overload Neurogenic: head injury
61
ddx for pulmonary oedema
Asthma/ COPD Pneumonia (may co-exist)
62
3 Sx of pulmonary oedema
Dyspnoea Orthopnoea Pink frothy sputum
63
Signs of pulmonary oedema
Distressed Tachycardic Tachypnoeic Pulsus alternans Raised JVP Fine lung crackles Wheeze
64
Ix for pulmonary oedema
BNP: ?HF U+Es Troponin: ?MI ECG: ?MI, dysrrhythmia CXR: ABCDE +/- echo
65
LVF on CXR
Alveolar oedema "bats wing" kerley B lines Cardiomegaly Dilated prominent upper lobe veins/ upper lobe diversion E pleural Effusion
66
How would you manage a patient with acute pulmonary oedema?
1. Sit upright + high flow O2 2. IV access + monitor ECG 3. Diamorphine 5mg IV 4. Furosemide 40-80mg IV 5. GTN spray SL (not if SBP <90) Consider further furosemide, nitrate infusion, CPAP

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