Respiratory

Question 1

LENT score

Answer 1

For malignant pleural effusion (prognostic scoring system)

- Pleural fluid LDH, ECOG, neutrophil-tolymphocyte ratio, tumor type

Question 2

Diagnosis of mesothlioma

Answer 2

• Pleural biopsy via thoracoscopy (highest diagnostic yield) -> histology and immunohistochemistry
• Serum mesothelin and fibulin 3: markers (mesothelin more diagnostic, fibulin more prognostic information)

Question 3

Work up for FEV1/FVC < LLN

Answer 3

VC ≥ LLN: obstruction 
VC < LLN
- TLC ≥ LLN: obstruction 
- TLC < LLN: mixed defect 
If obstruction 
- DLCO ≥ LLN: asthma, Chronic bronchitis
- DLCO < LLN: emphysema

Question 4

Work up for FEV1/FVC ≥ LLN

Answer 4

If VC ≥ LLN: normal ->
-  DLCO ≥ LLN: normal 
-  DLCO < LLN:: PV disorders 
If VC < LLN 
- TLC ≥ LLN: obstruction 
- TLC < LLN: restriction (if  DLCO ≥ LLN -> CW and NM disorders; if DLCO < LLN -> ILD, pneumonitis)

Question 5

Extrathoracic obstruction

Answer 5

• Vocal cord paralysis

- Vocal cord dysfunction

Question 6

Oxygen dissociation curve

Answer 6

percentage saturation of Hb (y) at various partial pressure of oxygen (x) 
Shift L (lower O2 delivery to tissues): lower H+, lower temp, lower 2,3DPG 
Shift R (higher O2): higher H2, higher temp, higher 2,3DPG

Question 7

RAPID score

Answer 7

• Clinical risk score for identifying risk for poor outcome with pleural effusion
  Renal - urea, Age, Purulence, Infection source, Dietary factors - albumin

Question 8

Evidence for intrapleural tissue plasminogen activator and Dornase alfa (DNase)

Answer 8

improve fluid drainage and reduce frequency of surgical referral and the duration of hospital stay (MIST 2)

Question 9

Indications for pleural space drainage

Answer 9

• Large free flowing pleural effusion more than 50% hemithorax OR
• Positive culture OR
• Positive gram stain OR
• pH < 7.2 suggesting presence of pus

Question 10

ILD resolve with smoking cessation

Answer 10

Distal interstitial pneumonia (DIP)

Respiratory associated bronchiolitis associated ILD

Question 11

Biomarkers for guarded prognosis from covid 19 pneumonia

Answer 11

- D-dimer, cardiac trop I, serum ferritin, LDH, IL-6 
NOT lymphocyte (baseline higher in survivors than non-survivors)

Question 12

Pulmonary rehab in COPD

Answer 12

Improve 
- Emotional function 
- Exertional dyspnea
- QoL
- Exercise tolerance
But NOT lung function

Question 13

Mechanism of hyperCa in sarcoidosis

Answer 13

Main mechanism
- Increased intestinal Ca absorption induced by high serum calcitriol concentration
- Activated mononuclear cells (esp macrophages) in the lung and LN in sarcoidosis and other granulomatous disease -> produce calcitriol from calcidiol independent of PTH
Other mechanism: PTHrP secreted from granulomatous tissue

Question 14

Lofgren syndrome

Answer 14

Subtype of acute sarcoidosis (good prognosis, >90% disease resolution within 2 years)
Triad of 
- Erythema nodosum
- Bilateral hilar adenopathy 
- Arthritis

Question 15

PET scan

Answer 15

3 clinical settings

1) solitary pulmonary nodules - distinguish benign vs malignant (not useful when lesion <1cm)
2) Carcinoma staging
3) surveillance - great sens and spec for detecting recurrence or persistent malignant disease from changes caused by radiation or surgery

Hyperglycaemia can reduce intracellular uptake of radioactive substrate FDG

Question 16

S/E of LAMA

Answer 16

• Dry mouth (most frequently reported)
  Dyspepsia, gastroenteritis, insomnia, irritation affecting nasal and throat passages
  Cautious with narrow-angle glaucoma and urinary retention, renal impairment

Question 17

Prognosis for SCLC, NSCLC and carcinoid

Answer 17

Carcinoid > NSCLC > SCLC

Question 18

Clinical tool - highest accuracy of predicting patients requiring intensive respiratory and ventilatory support (IRVS)

Answer 18

SMART-COP ≥ 3 - 92% who received IRVS

Question 19

Index for mortality, hospital readmission from 3 months to 1 year after discharge
in COPD patients

Answer 19

CODEX index (comorbidity, obstruction, dyspnea, previous severe exacerbations)

Question 20

systemic thrombolysis vs Catheter directed thrombolysis

Answer 20

• No difference in 30 day mortality rate
• No difference in-hospital mortality
• Increase risk of major haemorrhage

Question 21

Rivaroxaban > dabigatran

Answer 21

If history of dyspepsia

Question 22

Age adjustment D-dimer

Answer 22

Age X 10 in patients > 50 years

Question 23

Asthma-COPD overlap syndrome

Answer 23

Airflow limitation is not fully reversible, but often with current or historical variability

Question 24

Endobronchial valve placement

Answer 24

Procedures: with bronchoscopy, valve prevent air inflow during insp and allow air and mucus to exit during expiration
Beneficial for severe heterogeneous emphysema
- Improve lung function, dyspnea, exercise tolerance and QoL, safety profile
AVOID in severe bronchiectasis, fibrosis, severe paraseptal emphysema -> poor prognosis

Question 25

Long term O2 therapy for COPD

Answer 25

Indication: severe resting hypoxaemia - PaO2 ≤ 55mmHg or SpO2 ≤ 88% at least 15 hours to proven beneficial

Question 26

HFNP vs NIV for acute hypoxemic respiratory failure

Answer 26

- Increase patient comfort - Modest reduction in intubation - Modest reduction in hospital acquired pneumonia - Large reduction in all cause mortality - NOT reduced length of ICU stay

Question 27

Triple therapy for COPD

Answer 27

For patients already using LAMA/LABA dual therapy and have ongoing symptoms and risk for exacerbation Those with ≥ 2 % (or 150 absolute) eosinophils on blood do better with addition of ICS

Question 28

ICS withdrawal and ICS continuation in COPD

Answer 28

- Both decrease in absolute FEV1 (greater in withdrawal group) Possible reduce rates of pneumonia and minor infections e.g. oropharyngeal candidiasis

Question 29

Management of COPD that improves survival

Answer 29

- Smoking cessation - Long term O2 therapy - Lung transplant - Lung volume reduction therapy NOT ICS and LABA

Question 30

Ix of Kartagener syndrome

Answer 30

- Molecular testing for mutations in DNAI1 and DNAH5 (38% of primary ciliary dyskinesia) - Bronchoscopy: mucosal inflammation and mucopurulent secretions - Nasal biopsy (Brush or curettage) - Digital high speed video imaging (DHSV) of ciliary beat pattern

Question 31

Kartagener syndrome (subunit of primary ciliary dyskinesia)

Answer 31

Autosomal recessive disorder with genetic heterogeneity Caused by ciliary immotility/ dysmotlity due to ultrastructural abnormalities of resp cilia and flagella of spermatozoa and fallopian tube Clinical: situs invertus, resp distress of various severity -> chronic sinusitis and bronchiectasis. Flagella defects of spermatozoa and fallopian tube -> infertility/subfertility

Question 32

How to measure respiratory muscle weakness in motor neurone disease?

Answer 32

Measure maximal inspiratory pressure (MIP), maximal sniff nasal inspiratory pressure (SNIP) and maximal expiratory pressures (MEP) - MIP and SNIP reflect the strength of the diaphragm and other inspiratory muscles (if record low MIP -> confirm with SNIP) - MEP reflects the strength of abdominal muscle and other expiratory muscle

Question 33

Evidence of mandibular splint advancement

Answer 33

Suitable for mild to moderate disease or 2nd line who cannot tolerate CPAP Significant improvement in AHI and other indices a/w OSAS including snoring volume

Question 34

Severity of OSA

Answer 34

Mild: AHI 5-15 Moderate: AHI 15-30 Severe: ≥ 30

Question 35

How to calculate pulmonary ventilation?

Answer 35

Ventilation = RR X TV

Question 36

Riociguat - useful in which group of PHTN

Answer 36

Guanylate cyclase stimulators Dual mode of action: directly stimulate soluble guanylate cyclase independently of NO, increase sensitivity of soluble guanylate cyclase to NO -> increase level of cyclic guanosine monophosphate -> vasorelaxation and antiproliferative and antifibrotic effects In group IV: it improve exercise capacity and pulmonary vascular resistance in CTEPH (CHEST-1 trial)

Question 37

Selexipag - benefits and s/e

Answer 37

Use: pulmonary arterial hypertension Oral selective IP prostacyclin receptor agonist Reduce risk of hospitalisation and delay disease progression (Griphon study NEJM 2015) Most common s/e: headache

Question 38

Boyle's law and the importance in diving

Answer 38

Behavior of gases under varying amount of atmospheric pressure. If diver holds his breath at 100 feet, continues holding while rising to 10 feet then the gas in his lungs increase 4 times -> if forget to exhale on way up, lung explode