respiratory

Question 1

How is a pneumothorax managed?

Answer 1

if no or minimal symptoms - conservative care regardless of pneumothorax (minimal symptoms is defined as no significant pain, breathlessness and no physiological compromise)

if they are symptomatic - assess for high risk characteristics

high risk characteristics:
haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax

if not high risk characteristics are present - either conservative management, ambulatory device, needle aspiration

If high risk characteristics - chest drain

patients with a primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient
patients with a secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient
if stable, follow-up in the outpatients department in 2-4 weeks

Question 2

what is ambulatory care for pneumothorax ?

Answer 2

an example of an ambulatory device is the Rocketµ Pleural Vent„
it includes an 8FG catheter mounted on an 18G needle and a pigtail catheter to minimize the risk of occlusion
ambulatory devices typically have a one-way valve and vent to prevent air and fluid return to the pleural space while allowing for controlled escape of air and drainage of fluid
many devices also have an indication diaphragm that signals when the catheter tip enters the pleural space and continues to fluctuate with respiration, aiding in the assessment of pneumothorax resolution

Question 3

when can you fly after a pneumothorax?

Answer 3

absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray

Question 4

when can you scuba dive post pneumothorax?

Answer 4

the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’

Question 5

What is sarcoidosis?

Answer 5

a multisystem disorder of unknown aetiology characterised by non-caseasting granulomas.

Question 6

what are the features of sarcoidosis?

Answer 6

acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
insidious: dyspnoea, non-productive cough, malaise, weight loss
ocular: uveitis
skin: lupus pernio
hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)

Question 7

how is sarcoidosis investigated?

Answer 7

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.

Routine bloods may show hypercalcaemia (seen in 10% if patients) and a raised ESR

A chest x-ray may show the following changes:
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis

spirometry - restrictive defect
tissue biopsy - non-caseating granulomas

Question 8

how is sarcoidosis managed?

Answer 8

Indications for steroids
patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
hypercalcaemia
eye, heart or neuro involvement

Question 9

what factors in sarcoidosis are associated with poor prognosis?

Answer 9

insidious onset, symptoms > 6 months
absence of erythema nodosum
extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
CXR: stage III-IV features
black African or African-Caribbean ethnicity

Question 10

how are pleural effusions classified?

Answer 10

Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration.

Transudate < 30g/L protein

Exudate >30g/L proetein

Question 11

what are causes of transudate pleural effusions?

Answer 11

heart failure (most common transudate cause)
hypoalbuminaemia
liver disease
nephrotic syndrome
malabsorption
hypothyroidism
Meigs’ syndrome

Question 12

what are causes of exudate pleural effusions?

Answer 12

Infection - pneumonia, TB, subphrenic abscess
Connective tissue disease - RA, SLE
Neoplasia - lung Ca, mesothelioma, mets
pancreatitis
PE
Dressler’s syndrome
yellow nail syndrome

Question 13

when should LTOT be offered to patients?

Answer 13

LTOT should be offered to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
nocturnal hypoxaemia
peripheral oedema
pulmonary hypertension

Question 14

what is the general management of COPD?

Answer 14

> smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD

Question 15

what is the medical management of COPD?

Answer 15

1st line - SABA or SAMA
if they remain breathless or have exacerbations the next step is to determine if the patient has asthmatic features suggesting steroid responsiveness

No asthmatic features
add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
if already taking a SAMA, discontinue and switch to a SABA

Asthmatic features
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
if already taking a SAMA, discontinue and switch to a SABA
NICE recommend the use of combined inhalers where possible

Question 16

what features suggest a patient with COPD has asthmatic/steroid responsive features?

Answer 16

any previous, secure diagnosis of asthma or of atopy
a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)

Interestingly NICE do not recommend formal reversibility testing as one of the criteria. In the guidelines they state that ‘routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids

Question 17

when is theophylline used in COPD?

Answer 17

NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Question 18

when is prophylactic abx therapy indicated in COPD ?

Answer 18

azithromycin prophylaxis is recommended in select patients
patients should not smoke, have optimised standard treatments and continue to have exacerbations
other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis)
LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval

Question 19

when should a rescue pack for COPD be provided to patients?

Answer 19

have had an exacerbation within the last year
understand how to take the medication, and are aware of associated risks and benefits
know to when to seek help and when to ask for replacements once medication has been used

Question 20

when are PDE-4 inhibitors recommended in COPD?

Answer 20

Phosphodiesterase-4 (PDE-4) inhibitors

oral PDE-4 inhibitors such as roflumilast reduce the risk of COPD exacerbations in patients with severe COPD and a history of frequent COPD exacerbations

NICE recommend if:
the disease is severe, defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal, and
the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid

Question 21

which type of lung cancer is not necessarily associated with smoking?

Answer 21

Adenocarcinoma

Question 22

what are the features of squamous cell lung Ca?

Answer 22

Squamous cell lung cancers are strongly associated with smoking
They can cavitate and sometimes appear as cavitating lesions on chest x-ray. In addition, they are associated with hypercalcemia.

Question 23

what are the features of small cell lung cancer?

Answer 23

Small cell carcinomas account for about 20% of lung cancers. They are the most aggressive type of lung cancer and have usually metastasized by the time of diagnosis
The are also associated with hyponatraemia.

Question 24

what are risk factors for lung cancer?

Answer 24

Smoking
increases risk of lung ca by a factor of 10

Other factors
asbestos - increases risk of lung ca by a factor of 5
arsenic
radon
nickel
chromate
aromatic hydrocarbon
cryptogenic fibrosing alveoli’s

Smoking and asbestos are synergistic, i.e. a smoker with asbestos exposure has a 10 * 5 = 50 times increased risk

Question 25

what is the mechanism of action of bupropion and what is it used for

Answer 25

Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist. Bupropion is an atypical antidepressant and smoking cessation aid. should be started 1 to 2 weeks before the patients target stop date there is a small risk of seizures contraindicated in epilepsy, pregnancy and breast feeding having an eating disorder is a relative contraindication

Question 26

what is the mechanism of action of Vareniciline and what is it used for ?

Answer 26

Nicotinic receptor partial agonist Varenicline works by partially activating the nicotinic acetylcholine receptor, reducing cravings for nicotine and withdrawal symptoms. should be started one week prior to the target stop date course of treatment is 12 weeks nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline contraindicated in pregnancy and breast feeding

Question 27

what are predisopsing factors for OSA?

Answer 27

obesity macroglossia: acromegaly, hypothyroidism, amyloidosis large tonsils Marfan's syndrome

Question 28

what are the symptoms of OSA?

Answer 28

daytime somnolence compensated respiratory acidosis hypertension

Question 29

how do you diagnose OSA?

Answer 29

Assessment of sleepiness Epworth Sleepiness Scale - questionnaire completed by patient +/- partner Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria) Diagnostic tests sleep studies (polysomnography) - ranging from monitoring of pulse oximetry at night to full polysomnography where a wide variety of physiological factors are measured including EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry

Question 30

how is OSA managed?

Answer 30

weight loss CPAP intraoral devices the DVLA should be informed if OSAHS is causing excessive daytime sleepiness

Question 31

which investigations are indicated in COPD?

Answer 31

post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70% chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer full blood count: exclude secondary polycythaemia body mass index (BMI) calculation ** Measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction.

Question 32

How is COPD severity categorised?

Answer 32

FEV1 (of predicted value) > 80% Stage 1 - Mild - symptoms should be present to diagnose COPD in these patients 50-79% Stage 2 - Moderate 30-49% Stage 3 - Severe < 30% Stage 4 - Very severe

Question 33

what is the most common organism found in bronchiectasis?

Answer 33

Haemophilus influenzae (most common) other common organisms Pseudomonas aeruginosa Klebsiella spp. Streptococcus pneumoniae

Question 34

how is bronchiectasis managed?

Answer 34

physical training (e.g. inspiratory muscle training) - has a good evidence base for patients with non-cystic fibrosis bronchiectasis postural drainage antibiotics for exacerbations + long-term rotating antibiotics in severe cases bronchodilators in selected cases immunisations surgery in selected cases (e.g. Localised disease)

Question 35

what is bronchiectasis?

Answer 35

Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation

Question 36

what are the main indications for placing a chest tube in pleural infection ?

Answer 36

Patients with frankly purulent or turbid/cloudy pleural fluid on sampling should receive prompt pleural space chest tube drainage. The presence of organisms identified by Gram stain and/or culture from a non-purulent pleural fluid sample indicates that pleural infection is established and should lead to prompt chest tube drainage. Pleural fluid pH < 7.2 in patients with suspected pleural infection indicates a need for chest tube drainage.

Question 37

pleural aspiration

Answer 37

as above, ultrasound is recommended to reduce the complication rate a 21G needle and 50ml syringe should be used fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology

Question 38

what is light's criteria ?

Answer 38

Light's criteria was developed in 1972 to help distinguish between a transudate and an exudate. exudates have a protein level of >30 g/L, transudates have a protein level of <30 g/L if the protein level is between 25-35 g/L, Light's criteria should be applied. An exudate is likely if at least one of the following criteria are met: 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

Question 39

what do the following characteristics of pleural fluid suggest: - low glucose - raised amylase - heavy blood staining

Answer 39

low glucose: rheumatoid arthritis, tuberculosis raised amylase: pancreatitis, oesophageal perforation heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis

Question 40

what are pleural plaques?

Answer 40

Pleural plaques are benign and do not undergo malignant change. They, therefore don't require any follow-up. They are the most common form of asbestos-related lung disease and generally occur after a latent period of 20-40 years.

Question 41

What are the features of asbestosis?

Answer 41

The severity of asbestosis is related to the length of exposure. This is in contrast to mesothelioma where even very limited exposure can cause disease. The latent period is typically 15-30 years. Asbestosis typically causes lower lobe fibrosis. Features dyspnoea and reduced exercise tolerance clubbing bilateral end-inspiratory crackles lung function tests show a restrictive pattern with reduced gas transfer It is treated conservatively - no interventions offer a significant benefit.

Question 42

what is mesothelioma?

Answer 42

Mesothelioma is a malignant disease of the pleura. Crocidolite (blue) asbestos is the most dangerous form. Possible features progressive shortness-of-breath chest pain pleural effusion Patients are usually offered palliative chemotherapy and there is also a limited role for surgery and radiotherapy. Unfortunately, the prognosis is very poor, with a median survival from diagnosis of 8-14 months.

Question 43

what is the most common form of cancer caused by asbestos ?

Answer 43

Whilst mesothelioma is in some ways synonymous with asbestos, lung cancer is actually the most common form of cancer associated with asbestos exposure. It also has a synergistic effect with cigarette smoke in terms of the increased risk. Therefore, smoking cessation is very important as the risk of lung cancer in smokers who have a history of asbestos exposure is very high.

Question 44

what are the contraindication to surgery in patients with non-small cell lung cancer?

Answer 44

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

Question 45

how is non-small cell lung cancer managed?

Answer 45

only 20% suitable for surgery mediastinoscopy performed prior to surgery as CT does not always show mediastinal lymph node involvement curative or palliative radiotherapy poor response to chemotherapy

Question 46

what are the most common causes of COPD exacerbation?

Answer 46

bacteria Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis *if CXR showed pneumonia then step pneumonia would be the most common causative organism respiratory viruses account for around 30% of exacerbations human rhinovirus is the most important pathogen

Question 47

how is exacerbation of COPD managed?

Answer 47

Increase the frequency of bronchodilator use and consider giving via a nebuliser give prednisolone 30 mg daily for 5 days it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.

Question 48

when is admission required in exacerbation of COPD?

Answer 48

severe breathlessness acute confusion or impaired consciousness cyanosis oxygen saturation less than 90% on pulse oximetry. social reasons e.g. inability to cope at home (or living alone) significant comorbidity (such as cardiac disease or insulin-dependent diabetes)

Question 49

when is NIV indicated in exacerbation of COPD?

Answer 49

typically used for COPD with respiratory acidosis pH 7.25-7.35 the BTS guidelines state that NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used bilevel positive airway pressure (BiPaP) is typically used with initial settings: Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O

Question 50

how is acute asthma classified?

Answer 50

moderate PEFR 50-75% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm Severe PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm life threatening PEFR < 33% best or predicted Oxygen sats < 92% 'Normal' pC02 (4.6-6.0 kPa) Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma 'Near-fatal asthma', is also recognised characterised by a raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.

Question 51

how is asthma attack managed?

Answer 51

admission - life threatening, severe if they do not respond to treatment, previous near-fatal asthma attack, pregnancy oxygen bronchidialation - SABA Corticosteroid - 40mg of prednisone daily Ipratropium bromide IV magnesium sulphate IV aminophylline intubation ECMO

Question 52

what are the indications for NIV?

Answer 52

COPD with respiratory acidosis pH 7.25-7.35 type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea cardiogenic pulmonary oedema unresponsive to CPAP weaning from tracheal intubation

Question 53

what is catamenial pneumothorax ?

Answer 53

Catamenial pneumothorax is an uncommon and rather complex clinical condition which occurs due to endometrial tissues and is generally encountered in reproductive women. The mean ages are between 32-35 years old. In most of the cases, it involves the right side presenting with shortness of breath or difficulty breathing, fatigue, and dry cough. It can produce monthly episodes of chest pain which may radiate to the shoulder.

Question 54

what is Meigs' syndrome?

Answer 54

Meigs' syndrome consists of the classical triad of ascites, pleural effusion, and benign ovarian tumour e.g. ovarian fibroma and usually resolves following resection of the tumour.

Question 55

what is eosinophilic granulomatosis with polyangitis ?

Answer 55

Eosinophilic granulomatosis with polyangiitis (EGPA) is now the preferred term for Churg-Strauss syndrome. It is an ANCA associated small-medium vessel vasculitis. Features asthma blood eosinophilia (e.g. > 10%) paranasal sinusitis mononeuritis multiplex pANCA positive in 60% Leukotriene receptor antagonists may precipitate the disease.

Question 56

what medication should be avoided in Churg-Strauss syndrome?

Answer 56

Leukotriene receptor antagonists may trigger eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) Montelukast

Question 57

What are the steps of asthma management?

Answer 57

1 - Newly-diagnosed asthma Short-acting beta agonist (SABA) 2 - Not controlled on previous step OR Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking SABA + low-dose inhaled corticosteroid (ICS) 3 - SABA + low-dose ICS + leukotriene receptor antagonist (LTRA) 4- SABA + low-dose ICS + long-acting beta agonist (LABA) Continue LTRA depending on patient's response to LTRA 5- SABA +/- LTRA Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS 6- SABA +/- LTRA + medium-dose ICS MART OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA 7- SABA +/- LTRA + one of the following options: increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART) a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline) seeking advice from a healthcare professional with expertise in asthma

Question 57

what is MART?

Answer 57

Maintenance and reliever therapy (MART) a form of 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 MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)

Question 58

what are the investigations for lung cancer?

Answer 58

CXR (10% of CXR are reported as normal) CT Bronchoscopy PET scanning Bloods - may have raised platelets

Question 59

what is Lofgren's syndrome ?

Answer 59

Lofgren's syndrome is an acute form sarcoidosis characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It typically occurs in young females and carries an excellent prognosis.

Question 60

causes of upper zone pulmonary fibrosis?

Answer 60

hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis) coal worker's pneumoconiosis/progressive massive fibrosis silicosis sarcoidosis ankylosing spondylitis (rare) histiocytosis tuberculosis radiation-induced pulmonary fibrosis may develop following radiotherapy for breast or lung cancer typically seen between 6 and 12 months following completion of radiotherapy course Acronym for causes of upper zone fibrosis: CHARTS C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis

Question 61

causes of lung fibrosis predominately effecting the lower zones?

Answer 61

idiopathic pulmonary fibrosis most connective tissue disorders (except ankylosing spondylitis) e.g. SLE drug-induced: amiodarone, bleomycin, methotrexate asbestosis Causes of lower zone pulmonary fibrosis: Most connective tissue diseases (e.g. rheumatoid arthritis) Asbestosis Idiopathic pulmonary fibrosis Drugs (e.g. methotrexate)

Question 62

what are the pulmonary manifestations of rheumatoid arthritis?

Answer 62

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

Question 63

What is Brinchiololitis obliterates

Answer 63

progressive dyspnoea obstructive pattern on spirometry centrilobular nodules, bronchial wall thickening is seen on CT symptoms of dyspnoea, non-productive cough, expiratory wheeze and obstructive pattern on spirometry strongly suggests bronchiolitis obliterans. Obstructive pattern on spirometry is evidenced by decreased ratio of FEV1 and FVC.

Question 64

what leads to a left shift of the oxygen dissociation curve?

Answer 64

Shifts to Left = Lower oxygen delivery HbF, methaemoglobin, carboxyhaemoglobin Low [H+] (alkali) Low pCO2 Low 2,3-DPG Low temperature

Question 65

What leads to a right shift in the oxygen dissociation curve?

Answer 65

Raised [H+] (acidic) Raised pCO2 Raised 2,3-DPG Raised temperature

Question 66

causes of raised total gas transfer?

Answer 66

Causes of a raised TLCO asthma pulmonary haemorrhage (e.g. granulomatosis with polyangiitis, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise

Question 67

causes of lower total gas transfer?

Answer 67

Causes of a lower TLCO pulmonary fibrosis pneumonia pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output

Question 68

indications for steroids in sarcoidosis?

Answer 68

patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment hypercalcaemia eye, heart or neuro involvement

Question 69

The most common infective causes of COPD exacerbations are:

Answer 69

bacteria Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis respiratory viruses account for around 30% of exacerbations human rhinovirus is the most important pathogen

Question 70

what would be seen on spirometry in obstructive lung disease?

Answer 70

FEV1 - significantly reduced FVC - reduced or normal FEV1% (FEV1/FVC) - reduced

Question 71

what would be seen in spirometry of restrictive lung disease?

Answer 71

FEV1 - reduced FVC - significantly reduced FEV1% (FEV1/FVC) - normal or increased

Question 72

Causes of obstructive lung disease?

Answer 72

Asthma COPD Bronchiectasis Bronchiolitis obliterans

Question 73

causes of restrictive lung disease?

Answer 73

Pulmonary fibrosis Asbestosis Sarcoidosis Acute respiratory distress syndrome Infant respiratory distress syndrome Kyphoscoliosis e.g. ankylosing spondylitis Neuromuscular disorders Severe obesity

Question 74

What is the best investigation to assess for possible compression of the upper airways?

Answer 74

Flow volume loop is the investigation of choice for upper airway compression

Question 75

what is sarcoidosis?

Answer 75

Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating granulomas. It is more common in young adults and in people of African descent

Question 76

what are the features of sarcoidosis?

Answer 76

Features acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia insidious: dyspnoea, non-productive cough, malaise, weight loss ocular: uveitis skin: lupus pernio hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)

Question 77

what is Lofgren's syndrome?

Answer 77

associated with sarcoidosis Lofgren's syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis

Question 78

what is Mikulicz syndrome?

Answer 78

In Mikulicz syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma associated with sarcoidosis

Question 79

What is Hereford's syndrome?

Answer 79

associated with sarcoidosis Heerfordt's syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

Question 80

diet recommendations for cystic fibrosis?

Answer 80

high calorie diet, including high fat intake

Question 81

management of CF?

Answer 81

egular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful high calorie diet, including high fat intake* patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa vitamin supplementation pancreatic enzyme supplements taken with meals lung transplantion chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation Lumacaftor/Ivacaftor (Orkambi) is used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation lumacaftor increases the number of CFTR proteins that are transported to the cell surface ivacaftor is a potentiator of CFTR that is already at the cell surface, increasing the probability that the defective channel will be open and allow chloride ions to pass through the channel pore

Question 82

what age group is lung carcinoid seen in ?

Answer 82

40-50 years

Question 83

features of lung carcinoid?

Answer 83

typical age = 40-50 years smoking not risk factor slow growing: e.g. long history of cough, recurrent haemoptysis often centrally located and not seen on CXR 'cherry red ball' often seen on bronchoscopy carcinoid syndrome itself is rare (associated with liver metastases)