Respiratory Flashcards

Question

What are the possible features of mesothelioma?

Answer 1

progressive shortness-of-breath chest pain pleural effusion

Answer 2

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.

Answer 3

lung cancer is actually the most common form of cancer associated with asbestos exposure.

Answer 4

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.

Answer 5

Asthma is a common disease of the airways, involving reversible bronchoconstriction, hyperreactivity and chronic inflammation

Answer 6

intermittent ""asthma attacks"" with wheeze, cough, shortness of breath and chest tightness. The above symptoms should be episodic and usually show diurnal variation (worse at night or in the early morning).

Answer 7

allergic rhinitis, and eczema

Answer 8

Cold air and exercise Pollution and cigarette smoke Allergens such as animal dander, dust mites and pollen Irritants such as perfumes, paints or air fresheners Medications such as NSAIDs or beta-blockers

Answer 9

These trigger a type 1 hypersensitivity reaction which is mediated by IgE. T Helper 2 cells produce IL4, IL5 and IL13 cytokines which activate the humoral immune system, leading to the proliferation of eosinophils, mast cells and dendritic cells. These cells then produce more inflammatory mediators such as leukotrienes and histamine. This inflammation contributes to airway hyperresponsiveness leading to bronchospasm, as well as mucus hypersecretion that also obstructs airways. Over time in severe asthma, airway remodelling mediated by fibroblasts causes chronic obstruction and thickening of smooth muscle.

Answer 10

Family history of asthma or atopy Personal history of atopy (eczema, allergic rhinitis, allergic conjunctivitis) Exposure to smoke, including maternal smoking in pregnancy Respiratory infections in infancy Prematurity and low birth weight Obesity Social deprivation Occupational exposures (e.g. flour dust, isocyanates from paint)

Answer 11

Tachypnoea Increased work of breathing Hyperinflated chest Expiratory polyphonic wheeze throughout the lung fields Decreased air entry (if severe)

Answer 12

FeNO (fractional exhaled nitric oxide) testing: offer to all adults to confirm eosinophilic airway inflammation, considered positive if >40 parts per billion. Spirometry: offer to all > 5 years old to confirm airway obstruction (i.e. FEV1/FVC<70%), may be normal if patient is not symptomatic at the time of testing. Bronchodilator reversibility: if spirometry confirms obstruction, a bronchodilator (e.g. salbutamol inhaler) is given and spirometry repeated to assess response to treatment. An improvement in FEV1 of 12% or more or 200ml is a positive result.

Answer 13

may be falsely negative in patients treated with inhaled corticosteroids

Answer 14

If there is diagnostic uncertainty following the above tests, patients may be asked to monitor their peak flow twice a day over 2-4 weeks and keep a diary of the readings. This is then used to assess peak flow variability (the difference between the highest and lowest readings as a percentage of the average PEF). Variability >20% is a positive result If there is still uncertainty, patients may be referred to specialist services for a direct bronchial challenge test, where histamine or metacholine is inhaled to trigger bronchoconstriction. Airway hyperresponsiveness is assessed by looking at the concentration of the triggering medication required to cause a 20% decrease in FEV1 - 8mg/ml or less is a positive result.

Answer 15

Teach good inhaler technique and review this regularly Spacer devices can be used to optimise medication delivery Regular peak flow monitoring Smoking cessation Advice on avoiding triggers where possible (e.g. allergens, certain medications) Ensure vaccinations are up to date, including annual influenza vaccination Assess for occupational asthma by asking if symptoms are better when the patient is away from work and arrange specialist referral if this is suspected

Answer 16

Prescribe all patients a short-acting beta-2 agonist (SABA) such as salbutamol to use as a reliever inhaler Patients using a SABA 3 times per week or more/with asthma symptoms 3 times per week or more/who wake at night once a week or more also need an inhaled corticosteroid (ICS) which is started at a low dose (200mg), such as beclomethasone.

Answer 17

a leukotriene receptor antagonist (LTRA) such as montelukast - this is a tablet taken every night.

Answer 18

The next step would be adding a long-acting beta-2 agonist (LABA) such as salmeterol - the ICS should be continued but the LTRA may be stopped if it was not felt to have been of benefit.

Answer 19

switched to a regimen of low dose ICS + maintenance and reliever therapy inhaler (MART) +/- LTRA

Answer 20

MART is a combination inhaler with ICS and a fast-acting LABA (e.g. beclomethasone + formoterol which is also known as Fostair), which is used as both a reliever inhaler and as maintenance treatment.

Answer 21

The next step would be increasing the ICS dose from low to moderate, either continuing with a MART inhaler or going back to separate inhalers. At this stage consider referral to secondary care.

Answer 22

switching to a high dose ICS, oral steroid treatment or an additional medication (e.g. a muscarinic receptor antagonist or theophylline). This would usually be under a specialist clinic, and patients may also be able to access newer therapies such as biologics (e.g. omalizumab, which targets IgE)

Answer 23

Uncertainty regarding diagnosis Suspected occupational asthma Severe or life-threatening asthma requiring admission to hospital Multiple exacerbations requiring oral steroid treatment per year

Answer 24

PEFR > 50% of predicted or best No features of severe/life-threatening asthma

Answer 25

PEFR 33-50% of predicted or best Heart rate > 110 Respiratory rate > 25 Unable to complete sentences in one breath. Accessory muscle use Normal CO2

Answer 26

PEFR < 33% of predicted or best Oxygen saturation < 92% or cyanosis Altered conciousness/confusion Exhaustion/poor respiratory effort Cardiac arrhythmia Hypotension Silent chest PaO2 < 8kPa Normal PaCO2 - suggest that the patient has life-threatening asthma, as it would be initially low due to hyperventilation. As the patient tires, they become normocapnic then hypercapnic

Answer 27

Peak expiratory flow rate (PEFR) to help assess severity as per the classification above and monitor response to treatment. Arterial blood gas if the patient is hypoxic to assess oxygenation and ventilation in patients - CO2 is expected to be low due to hyperventilation and if this is raised this indicates the asthma attack is near fatal. Portable chest X-ray if a trigger such as pneumonia or a complication such as pneumothorax is suspected clinically.

Answer 28

Recognise that this may be a medical emergency, assess using an ABCDE approach and escalate early to senior colleagues/critical care if not responding to treatment Titrate oxygen to maintain saturations of 94-98% Nebulised salbutamol driven by oxygen (if out of hospital, give up to 10 puffs of inhaled salbutamol and call an ambulance if not responding) The BNF advises that patients should take 40-50mg prednisolone for ≥5days following an acute asthma episode. A Cochrane review of six trials indicated that a short course of corticosteroids could reduce the risk of relapse following an acute exacerbation of asthma. The first dose can be given in A&E

Answer 29

If the attack is severe or life-threatening or if response to salbutamol has been poor, add nebulised ipratropium bromide Give prednisolone 40-50mg orally, or IV hydrocortisone if the patient is unable to swallow Can consider IV magnesium sulphate and/or aminophylline if the patient is not responding to nebulisers If the patient continues to deteriorate despite maximal therapy, they may require intubation and ventilation in an intensive care setting (for example in cases of severe hypoxia or exhaustion)

Answer 30

Within 2 days

Answer 31

oral thrush, which is associated with steroid inhaler use. The risk of oral thrush can be reduced with correct inhaler technique, using a spacer with the inhaler and rinsing and spitting after inhaler use. The problem may be persistent, in which case, alternative causes, such as immunosuppression from malignancy or diabetes, should be excluded, and the patient may require nystatin therapy

Answer 32

Curschmann spirals

Answer 33

A stable period of 24 hours on the regular asthma treatment regime

Answer 34

asthma, nasal polyps and aspirin sensitivity (sometimes also known as Aspirin Exacerbated Respiratory Disease or AERD). It is very classical for patients with asthma to have worsening symptoms following aspirin, as well as beta blockers, and great care should be taken with these medications in this population

Answer 35

Typical spirometry results for obstructive respiratory disease are a low FEV1 and reduced FEV1/FVC (<70% predicted). FVC is preserved

Answer 36

respiratory alkalosis and hypoxemia

Answer 37

Bronchiectasis is a chronic lung disease where inflammation and obstruction causes damage to the bronchial walls leading to their permanent dilation. This damage may affect the whole lung or only one lobe (for example in cases caused by airway obstruction).

Answer 38

40% of patients will have no identifiable cause for their bronchiectasis. The most common identified cause is a previous severe lower respiratory tract infection, for example pneumonia, TB or influenza. Other causes of bronchiectasis include: Immunodeficiency (HIV, common variable immunodeficiency) Defective mucociliary clearance (cystic fibrosis, primary ciliary dyskinesia e.g. Kartagener syndrome) Allergic Bronchopulmonary Aspergillosis (ABPA) Autoimmune disease (rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease) Airway obstruction (inhaled foreign bodies, bronchial carcinoma, severe obstructive lung disease e.g. COPD/asthma) Chronic aspiration Congenital defects of the large airways (Marfan’s, tracheobronchomegaly)

Answer 39

Symptoms include: Productive cough lasting at least 8 weeks Copious production of purulent sputum Dyspnoea Haemoptysis Chest pain Fatigue Weight loss On examination patients may have: Coarse crackles on auscultation Wheeze Rhonchi (snoring sounds caused by secretions in the larger airways) Finger clubbing

Answer 40

Sputum culture: to look for colonising bacteria (specialist follow up is required for those carrying MRSA, pseudomonas or mycobacteria). Spirometry: to look for comorbid COPD and asthma and assess severity of obstruction. Blood tests: inflammatory markers (WCC, CRP) for infective exacerbations. Chest X-ray: usually abnormal, with increased lung markings, tram-track opacities and ring shadows. High-resolution CT chest: the diagnostic test for bronchiectasis, may also give an indication to the underlying cause and can be used to quantify severity. May show lack of tapering of airways, increased ratio of bronchi to adjacent pulmonary arteries, bronchial wall thickening and impacted mucus. - thickened bronchial walls in "tram-tracking" and "signet-ring" form

Answer 41

Rheumatoid factor, anti-CCP, ANA and ANCA Serum immunoglobulins: if low suspect antibody deficiency, if IgE raised may indicate ABPA HIV serology Testing for cystic fibrosis: genetic testing or sweat chloride, all under 40s should be tested as well as older patients with features of CF Bronchoscopy: should be done if bronchiectasis is focal to rule out an obstructing malignancy or foreign body

Answer 42

Patient education on self-management including sputum clearance exercises Smoking cessation support Referral to pulmonary rehabilitation for patients with disabling breathlessness Nutritional support for patients with a BMI < 20 Influenza and pneumococcal vaccination Chest physiotherapy e.g postural drainage

Answer 43

Identify acute exacerbations - these usually present with worsening breathlessness, increased sputum production, fevers and malaise - and treat with antibiotics tailored to sputum cultures Long-term antibiotic prophylaxis should be considered in patients with 3+ exacerbations per year or exacerbations causing significant morbidity - again this should be tailored to sputum cultures e.g. nebulised colomycin for carriers of Pseudomonas aeruginosa Treat comorbidities e.g. ensure on appropriate inhalers for asthma or COPD The initial management includes chest physiotherapy to facilitate the removal of secretions, inhaled bronchodilators to improve airflow, and antibiotics to treat bacterial infections. Other treatments such as mucolytics, macrolide antibiotics, and immunomodulators may also be used depending on the severity and underlying cause.

Answer 44

Lung resection may be considered in certain patients with localised disease in order to reduce exacerbations or treat haemoptysis Specialist services may also consider referral for lung transplantation in severe cases of bronchiectasis not responding to medical management

Answer 45

PCD is an autosomal recessive disorder of dysfunctional cilia. Cilia are important as they determine the orientation/laterality of internal organs and line the inner walls of bronchi. Consequently, their dysfunction results in bronchiectasis and recurrent infections. Percussion usually changes at the RIGHT lung base due to movement of the liver during inspiration and expiration. This patient displays this phenomena at their LEFT lung base, suggesting situs invertus – a key features of PCD

Answer 46

Haemophilus influenzae, Pseudomonas aeruginosa, TB, Bordetella pertussis (otherwise known as whooping cough) and Allergic Bronchopulmonary Aspergillosis (ABPA)

Answer 47

This may indicate bronchiectasis with possible superimposed bacterial infection. This would require hospital admission for IV antibiotics treatment.

Answer 48

a clinical condition characterised by persistent airflow limitation with several features usually associated with both asthma and chronic obstructive pulmonary disease (COPD). Patients exhibit increased reversibility of airflow obstruction, eosinophilic bronchial and systemic inflammation, and increased response to inhaled corticosteroids.

Answer 49

Genetic factors, environmental exposures - airborne pollutants and and allergen exposure, smoking, poorly controlled asthma, recurrent respiratory infections, increased age and female gender

Answer 50

a patient with a history of smoking, presenting with persistent breathlessness that is progressive and worsened by exercise. The patient may also have a chronic cough with expectoration, recurrent wheezing episodes often triggered by respiratory infections or exposure to allergens, and frequent exacerbations requiring systemic corticosteroids or antibiotics.

Answer 51

Respiratory Symptoms Dyspnoea: Patients commonly experience dyspnoea which is persistent, progressive and aggravated by exertion. It may be accompanied by orthopnoea in severe cases. Cough: Chronic cough is another common symptom, often productive with clear or white sputum. This may worsen in the morning or during the night. Wheezing and Chest Tightness Patients can present with recurrent wheezing episodes which are often triggered by respiratory infections or exposure to allergens. These episodes are associated with chest tightness and may not fully respond to bronchodilators. Exacerbations Frequent exacerbations requiring treatment with systemic corticosteroids or antibiotics are common in ACOS patients. These exacerbations are generally more severe than those seen in asthma or COPD alone.

Answer 52

might reveal prolonged expiration, wheezing on auscultation, hyperinflation of the chest and use of accessory muscles for respiration indicating respiratory distress. In advanced stages, signs of cor pulmonale such as peripheral oedema and raised jugular venous pressure may be observed.

Answer 53

These are essential for diagnosing ACOS as they provide objective evidence of airflow obstruction and reversibility, both hallmark features of this condition. Spirometry: This is the first-line investigation. A post-bronchodilator FEV1/FVC ratio less than 0.7 confirms persistent airflow limitation, suggestive of COPD. Evidence of reversibility (an increase in FEV1 by ≥12% and ≥200ml following bronchodilator administration) may suggest asthma. Bronchial Challenge Test: In cases where spirometry results are inconclusive, a bronchial challenge test with methacholine or histamine can be used to assess airway hyperresponsiveness, a characteristic feature of asthma.

Answer 54

Chest X-ray: This is usually the first-line radiological investigation. It can help identify alternative diagnoses or complications like pneumonia or pneumothorax. High-Resolution Computed Tomography (HRCT): This can be considered when there is suspicion of other co-existing conditions such as bronchiectasis or interstitial lung disease.

Answer 55

Full Blood Count (FBC): May show eosinophilia, often seen in asthma. IgE: Elevated levels can support a diagnosis of asthma but should not be used in isolation to diagnose ACOS.

Answer 56

Eosinophilic inflammation is more characteristic of asthma, while neutrophilic inflammation is more common in COPD. However, this test is not routinely performed due to its technical demands and limited availability.

Answer 57

Evaluate the severity of symptoms using validated tools such as the Medical Research Council (MRC) dyspnoea scale or COPD Assessment Test (CAT). Identify risk factors for exacerbations, including previous exacerbation history, high eosinophil count, poor lung function, smoking status and comorbidities.

Answer 58

Inhaled corticosteroids (ICS) combined with long-acting beta2-agonists (LABA) are the first-line therapy for most patients with ACOS. Add-on therapies such as long-acting muscarinic antagonists (LAMA) may be considered in patients who remain symptomatic or have frequent exacerbations despite ICS/LABA treatment. Consider short-acting bronchodilators for rescue therapy in all patients.

Answer 59

Promote smoking cessation in smokers. Provide support through counselling or pharmacotherapy if appropriate. Encourage regular physical activity and a balanced diet to maintain optimal body weight.

Answer 60

Coronaviruses are a family of single-strand positive sense RNA viruses, named for their crown-like appearance under electron microscopy. They can cause respiratory diseases in both animals and humans.

Answer 61

Three strains have caused pandemics: Severe Acute Respiratory Syndrome (SARS), Middle Eastern Respiratory Syndrome (MERS), and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2), also known as COVID-19.

Answer 62

Demographics: older age, male sex, ethnic minority populations Immunocompromise: immunosuppression, HIV Comorbidities including diabetes, respiratory, cardiovascular, renal, liver, neurological diseases

Answer 63

Typically, symptoms appear within 5 days of infection. Symptoms include fevers, cough, anosmia, dyspnoea, fatigue, myalgia, headache and diarrhoea. Complications can develop early or after several days. Symptoms of severe disease include worsening breathlessness, coughing up blood, cyanosis, cold/pale/mottled skin, collapse and altered mental status

Answer 64

Diagnosis of Covid-19 can be with rapid lateral flow tests or a swab sent for RT-PCR. For people with signs of severe disease or complications, consider the following: Bloods: FBC (may show lymphopenia), U&E, LFT, glucose, clotting, CRP, ESR, LFH, iron studies, cardiac markers as indicated ABG may show low PaO2, acidosis or raised PaCO2 Chest X-ray showing ground-glass opacity or consolidation Blood & sputum cultures

Answer 65

In a case of suspected or confirmed Covid-19, it is important to take precautions such as isolation & wearing appropriate PPE when interacting with positive cases. For most cases of mild infection, patients can be managed conservatively at home with advice on self-care and measures to reduce transmission. If they are at high risk of complications, antiviral or antibody treatment may be indicated.

Answer 66

If a patient has signs of severe disease or complications, admit to hospital. If they are acutely unwell, follow an A-E approach, get help early & consider initiating sepsis pathways. It is important to consider treatment escalation planning. Patients may require: Oxygen therapy if hypoxic Symptom management, for example analgesia or antipyretics Antivirals such as remdesivir Biologic treatments such as IL-6 inhibitors, or JAK inhibitors Steroids such as dexamethasone, especially if there is an oxygen requirement VTE prophylaxis Treatment of secondary infections Patients with critical illness may require ICU or HDU admission. They may need respiratory support (non-invasive ventilation, mechanical ventilation), prone positioning and specific treatments guided by specialists.

Answer 67

Acute respiratory distress syndrome Venous thromboembolism Heart failure & other cardiac pathology Acute kidney injury Acute liver injury Sepsis Paediatric multisystem inflammatory syndrome in children Neurological sequelae Secondary bacterial infection Long Covid

Answer 68

Chronic obstructive pulmonary disease (COPD) involves airway obstruction that is usually progressive.

Answer 69

Tobacco smoking and passive smoke exposure Marijuana smoking Occupational exposure to dusts and fumes Household air pollution from wood or coal burning Alpha-1 antitrypsin deficiency Prognosis is variable, with the following factors associated with higher morbidity and mortality: Poor exercise tolerance Smoking Low body mass index Multi-morbidity and frailty Exacerbations requiring admission to hospital or frequent exacerbations Severe obstruction on spirometry (as measured by a lower FEV1) Chronic hypoxia Cor pulmonale

Answer 70

Chronic bronchitis and emphysema

Answer 71

As a protective reaction to smoke or other pollutants, goblet cells hypersecrete mucus in the bronchi and bronchioles of the lungs. Cilia are not able to remove the excess mucus and so it obstructs the small airways. Ongoing inflammation causes remodelling and thickening of the airway walls that also contributes to obstruction.

Answer 72

Inflammation in the lungs is usually countered by antiproteases such as alpha-1 antitrypsin, however the activity of these is reduced by smoke and other pollutants. Without sufficient antiprotease activity, proteolytic enzymes produced by inflammatory cells break down the walls of the alveoli. This causes enlargement of the terminal airspaces and reduces the surface area available for gas exchange.

Answer 73

airflow limitation (as measured by FEV1), severity of symptoms and frequency of exacerbations.

Answer 74

CAT (COPD Assessment Test) and the mMRC (modified Medical Research Council) dyspnoea scale

Answer 75

Shortness of breath that worsens with exertion Reduced exercise tolerance Chronic productive cough Recurrent lower respiratory tract infections Wheeze In more advanced cases, systemic symptoms such as weight loss and fatigue may be present

Answer 76

Wheeze or crackles on auscultation Accessory muscle usage Pursed lip breathing (this creates a small amount of positive end expiratory pressure to prevent the alveoli from collapsing) Cyanosis Hyperinflation of the chest Cachexia Raised JVP and peripheral oedema (indicating cor pulmonale has developed)

Answer 77

spirometry Fev1/FVC ratio <0.7 confirms obstruction also do a Sputum culture - during exacerbations to target antibiotic therapy

Answer 78

Bloods - Full blood count looking for polycythaemia (resulting from chronic hypoxaemia) or anaemia (usually anaemia of chronic disease), consider BNP to assess for heart failure (with an echocardiogram if suspected, alpha-1 antitrypsin in young patients/minimal smoking history/strong family history ECG - the following ECG changes are often seen in advanced COPD with features of e.g. cor pulmonale, and include: Right axis deviation Prominent P waves in inferior leads Inverted P waves in high lateral leads (I, aVL) Low voltage QRS Delayed R/S transition in leads V1-V6 P pulmonale Right ventricular strain pattern RBBB Multifocal atrial tachycardia

Answer 79

used to rule out other causes of symptoms (e.g. lung cancer, bronchiectasis), may show features of COPD including hyperinflation of the chest with flattening of the hemidiaphragms and bullae.

Answer 80

Patient education, ensure all patients have a personalised self-management plan Smoking cessation support Nutritional support and dietician referral if malnourished Annual influenza and one-off pneumococcal vaccination Pulmonary rehabilitation (refer if grade 3 and above on mMRC dyspnoea scale or a recent admission for an acute exacerbation) Consider referral for respiratory physiotherapy to help with sputum clearance and breathing techniques

Answer 81

For patients whose activities are limited by breathlessness, start a short-acting beta-2 agonist (SABA, e.g. salbutamol) or short-acting muscarinic antagonist (SAMA, e.g. ipratropium) inhaler Bronchodilator therapy

Answer 82

The next step depends on if they have features of asthma or steroid responsiveness: if these are present then add a long-acting beta-2 agonist (LABA, e.g. formoterol) and an inhaled corticosteroid (ICS, e.g. beclomethasone, budesonide). If patients do not respond adequately to this, the third inhaler can then be trialled (i.e. all patients would be on a SABA/SAMA + LABA + LAMA + ICS).

Answer 83

add a LABA and a long-acting muscarinic antagonist (LAMA, e.g. tiotropium).

Answer 84

Patients who require further therapy should be referred to a specialist for ongoing management which may include oral steroids, oral theophylline or oral phosphodiesterase-4 inhibitors (e.g. roflumilast). Other medical treatments that may be considered include: Oral mucolytic therapy - for patients with a chronic cough productive of sputum. Prophylactic antibiotics - in cases of frequent infective exacerbations, should be discussed with a specialist, a common choice would be azithromycin 3x per week. Nebuliser therapy - for patients with disabling breathlessness despite optimised use of inhalers. Long-term oxygen therapy (LTOT) NICE recommends offering a short course of PO corticosteroids and PO antibiotics as standby medication for patients who have had multiple exacerbations of COPD within one year

Answer 85

Oxygen saturations <92% in air or cyanosis FEV1 <30% predicted (consider referring if <49%) Polycythaemia Peripheral oedema or raised jugular venous pressure (suggesting cor pulmonale) This assessment involves ensuring that patients are medically optimised and their COPD is stable (i.e. they’re not recovering from a recent exacerbation) Patients then have two ABGs in air at least 3 weeks apart and the following patients should be offered LTOT (with the advice to use the oxygen for at least 15 hours per day): PaO2 below 7.3kPa PaO2 7.3-8kPa with any of secondary polycythaemia (hematocrit would need to be >55% for polycythaemia to be diagnosed), nocturnal hypoxia, peripheral oedema or pulmonary hypertension (pulmonary artery pressure of >25mmHg)

Answer 86

Patients who are current smokers cannot be offered LTOT because of the risk of burns and fires.

Answer 87

In certain cases of severe COPD when patients have not responded to maximal medical therapies, surgical intervention may be considered. Particularly in patients where there is predominant upper lobe emphysema and sufficient lung function reserve Both the NICE recommended options involve lung volume reduction (which involves removing emphysematous areas of the lung so that the healthy lung can expand) - this can be done either by surgical resection or using bronchoscopy to site a one-way valve in one of the larger airways to collapse the diseased lung.

Answer 88

Depression and anxiety, pneumothorax, cor pulmonale, polycythaemia, acute exacerbations

Answer 89

These present with worsening breathlessness, productive cough and wheeze, and patients may be febrile, tachycardic and tachypnoeic. Patients who are clinically well may be treated at home with an increase in their usual inhalers, a short course of oral steroids (usually 30mg prednisolone for 5 days) and oral antibiotics if bacterial infection is suspected. Those who have frequent exacerbations may be given a “rescue pack” of steroids and antibiotics to keep at home and start using in case of an exacerbation (alongside seeking medical help). Patients requiring hospital admission should also receive steroids and antibiotics if indicated. They may require nebulised bronchodilators, supplementary oxygen and in case of deterioration respiratory support with non-invasive ventilation may be required. Advanced care planning and ensuring that escalation status is discussed with patients is therefore key, so that if they deteriorate to the point of needing intensive care support it is established whether or not this is appropriate and in line with their wishes.

Answer 90

Chronic tissue hypoxia as seen in COPD leads to a compensatory overproduction of erythropoietin, which leads to increased red blood cell production (i.e. secondary polycythaemia). This causes an increase in blood viscosity that in turns increases risk of both arterial and venous thrombosis.

Answer 91

Cor pulmonale refers to right ventricular dilation or hypertrophy in response to pulmonary hypertension caused by chronic lung disease - COPD is not the only cause of this but it is the most common. The pathophysiology is as follows: Changes in the lungs and chronic hypoxaemia cause the walls of the pulmonary arteries to thicken. This increases vascular resistance in the lungs. The right ventricle then has to pump against greater resistance, which causes it to either dilate or hypertrophy. Ultimately this leads to right heart failure, with resulting peripheral oedema, hepatomegaly and elevated jugular venous pressure (JVP). Peripheral oedema may be treated symptomatically with diuretics and long-term oxygen therapy has been shown to reduce morbidity and mortality. All patients with suspected cor pulmonale should be referred to secondary care.

Answer 92

These occur when a bulla ruptures, releasing air into the pleural cavity.

Answer 93

Over 1 in 3 people with COPD report symptoms of depression and anxiety so screening for this is important during patient reviews. The COPD Assessment Test (CAT) can be used to assess the impact of COPD on everyday life. Referral to psychological services for support may be appropriate, as well as holistic assessment and management.

Answer 94

IECOPD in the first instance are amoxicillin, doxycycline, or clarithromycin

Answer 95

The patient is of the 'blue bloater' phenotype of COPD where chronic bronchitis and hypoxaemia predominate. These patients are under-ventilated due to their chronic airway inflammation and a controlled reduction in respiratory rate; due to the increased energy required to get air through the narrowed airways, the body responds by increasing cardiac output instead. This leads to a low V/Q ratio, as ventilation is decreased compared to perfusion, which is maintained by the increased cardiac output

Answer 96

Reduction: The patient has a history of chronic obstructive pulmonary disease. The histology finding of destruction to the alveolar walls is indicative of emphysema. In this condition the DLCO is reduced due to the destruction of the alveolar wall, the surface available for diffusion is reduced

Answer 97

over-oxygenating him. achieving saturations of 96% he is losing his hypoxic drive and is hypoventilating. This is shown by his reduced work of breathing and looking calmer, which is in fact a decreasing level of consciousness due to CO2 narcosis. oxygen saturation should be aimed for 88-92%

Answer 98

Venturi mask

Answer 99

non-invasive ventilation with BiPAP is an effective intervention

Answer 100

initially provide high flow oxygen via non-rebreathe mask aiming for saturations of 94-98%, prioritising the treatment of hypoxemia over hypercapnia. hypoxia will cause death quicker than hypercapnia. If a patient is found to be a chronic retainer then you should aim for saturations of 88-92% by titrating the oxygen supply down

Answer 101

COPD severity can be classified according to the GOLD criteria, which uses a combination of FEV1/FVC ratios and symptoms to categorise patients: * GOLD A 0–1 exacerbations per year + fewer symptoms * GOLD B 0–1 exacerbations per year + more symptoms * GOLD C 2 or more exacerbations per year + fewer symptoms * GOLD D 2 or more exacerbations per year + more symptoms All patients who are classified as GOLD B or higher should be offered pulmonary rehabilitation. This consists of a structured programme of exercise and education. There is consistent evidence that these programmes reduce dyspnoea, fatigue and manage the emotional aspect of the diagnosis, leading to an overall improvement in quality of life.

Answer 102

Influenza or 'flu' is a single-stranded RNA virus infecting the respiratory tract.

Answer 103

three - A, B, C

Answer 104

determined by surface antigens haemagglutinin and neuraminidase, which are rearranged in host organisms such as birds and animals to produce different strains

Answer 105

Influenza A – capable of causing pandemics and epidemics; no animal reservoir Influenza B –capable of epidemics only, animal hosts include pigs and birds Influenza C – only found in cattle

Answer 106

Hyposplenism Chronic diseases of the respiratory, cardiovascular, renal, liver, neurological systems Diabetes mellitus Immunosuppression Morbid obesity Pregnancy

Answer 107

The incubation period is typically 1–4 days and patients can remain infectious for 7–21 days. Symptoms include: Fever ≥ 37.8°C Nonproductive cough Myalgia Headache Malaise Sore throat Rhinitis

Answer 108

When prevalence is high, uncomplicated influenza can be diagnosed clinically. If patients have severe symptoms or complications, rapid testing (PCR) and laboratory testing can be used but should not delay treatment.

Answer 109

manage with an A-E approach, seek help early and consider starting the sepsis six

Answer 110

Largely supportive (analgesia, antipyretic, fluids, oxygen) Antiviral treatment with neuraminidase inhibitors (eg. oseltamivir (Tamiflu®) or zanamivir if within 48 hours of symptom onset and at risk of complications. Oseltamivir may also be prescribed for previously healthy people presenting with influenza within 48 hours of treatment onset. Infection control and respiratory isolation to prevent onward transmission

Answer 111

Pulmonary – viral pneumonia, secondary bacterial pneumonia (particularly S. aureus) , worsening of chronic conditions (eg. COPD and asthma) Cardiovascular – myocarditis, heart failure Neurological – encephalopathy Gastrointestinal – anorexia and vomiting are common

Answer 112

Influenza vaccine is an inactivated vaccine tailored each year according to recent outbreaks. It provides partial protection against influenza and is recommended for certain patient groups (eg. those aged over 65, with chronic conditions, healthcare workers and nursing home residents).

Answer 113

interstitial lung disease (ILD) encompasses a large group of diseases that cause inflammation and ultimately fibrosis of the interstitium of the lung.

Answer 114

idiopathic pulmonary fibrosis and hypersensitivity pneumonitis.

Answer 115

a progressive, fibrotic lung disease of unknown cause It is the commonest form of ILD

Answer 116

usual interstitial pneumonitis The diagnosis can be made on HRCT alone if the characteristic signs of peripheral basal honeycombing are present.

Answer 117

Patients tend to be older (mean age of presentation is 74 years), male and it is more common in smokers.

Answer 118

Inhalation of specific environmental agents can trigger a hypersensitivity reaction in the lungs. This was previously known as "extrinsic allergic alveolitis". A one-off exposure to a trigger can cause acute onset flu-like symptoms such as fever, cough and shortness of breath

Answer 119

a type of hypersensitivity pneumonitis caused by mould spores on hay or straw Best investigation is Serum precipitins for Aspergillus and mould antigens

Answer 120

Sarcoidosis is a rare multisystem disease characterised by the formation of noncaseating granulomas Presentation depends on the organs affected Constitutional symptoms include fatigue, weight loss, low-grade fever, arthralgia, lymphadenopathy and enlarged parotid glands Pulmonary symptoms are the same as in other forms of ILD (dry cough, dyspnoea, reduced exercise tolerance)

Answer 121

Neurological manifestations include meningitis, peripheral neuropathies and Bell's palsy

Answer 122

Ocular manifestations include uveitis and keratoconjunctivitis sicca

Answer 123

include arrhythmias and restrictive cardiomyopathy

Answer 124

hepatomegaly, splenomegaly and renal stones

Answer 125

include erythema nodosum and lupus pernio

Answer 126

Lung damage due to infarction, pneumonia or tuberculosis Irritants such as coal dust or silica Connective tissue disease such as rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis or Sjogren's syndrome Medications including Amiodarone, Nitrofurantoin and Bleomycin. Radiation to the chest area (e.g. for breast cancer)

Answer 127

where in the lung is predominantly affected (apices or bases)

Answer 128

Hypersensitivity pneumonitis Ankylosing spondylitis Radiotherapy Tuberculosis

Answer 129

Rheumatoid arthritis Asbestosis Idiopathic Drugs Sarcoidosis

Answer 130

Symptoms tend to have an insidious and progressive onset, and may include: Dry cough Shortness of breath Reduced exercise tolerance Fatigue Anorexia Weight loss

Answer 131

Signs on examination include: Cyanosis Clubbing Cachexia Fine end-inspiratory crackles location depends on where in the lung is affected do not clear on coughing There may also be symptoms and signs of associated diseases e.g. arthropathy in connective tissue disease.

Answer 132

FBC may show eosinophilia in hypersensitivity pneumonitis U&Es, LFTs, bone profile to look for other manifestations of systemic disease (e.g. hypercalcaemia in sarcoidosis) CRP may be raised in ILD due to inflammation Autoimmune screen (rheumatoid factor, ANA, ANCA, ENA, Scl-70 antibodies) if connective tissue disease is suspected Serum precipitins to specific allergens (e.g. in bird fanciers' lung) Serum angiotensin-converting enzyme if sarcoidosis suspected

Answer 133

High resolution CT

Answer 134

Typical findings include honeycombing, ground-glass changes and traction bronchiectasis (where areas of contracting fibrosis pull the bronchioles apart)

Answer 135

Chest X-ray usually shows reticular and nodular shadowing The area of the lung affected can help to determine the cause of ILD Bilateral hilar lymphadenopathy may be seen in sarcoidosis

Answer 136

shows a restrictive pattern (FEV1/FVC ratio > 0.7), decreased total lung capacity and TLCO

Answer 137

Two antifibrotic drugs are currently licensed which slow the progression of fibrosis; these are pirfenidone (which reduces fibroblast proliferation) and nintedanib (a tyrosine kinase inhibitor) for FVC 50%-80% of predicted Other important management considerations include early palliative care involvement, consideration of ambulatory and long-term oxygen therapy if hypoxic and pulmonary rehabilitation Smoking cessation advice and support Referral for lung transplantation assessment if no absolute contraindications (e.g. active substance abuse)

Answer 138

There is the potential for reversal if the causative agent can be identified and removed If symptoms persist despite this, steroids should be trialled If there is no response to steroids, other immunosuppressive therapies may be considered (e.g. cyclophosphamide, azathioprine)

Answer 139

Low vital capacity (VC), total lung capacity (TLC), and transfer capacity of the lung carbon monoxide (TLCO).

Answer 140

Amiodarone, rugs that can cause pulmonary fibrosis include nitrofurantoin, methotrexate, bleomycin, busulfan and sulfasalazine. This usually requires months to years of exposure.

Answer 141

rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis or Sjogren's syndrome

Answer 142

A lower respiratory tract infection, also known as a chest infection, is an infection of the lower large airways and/or alveoli.

Answer 143

Acute bronchitis: acute inflammation of the bronchial airways with no evidence of pneumonia Pneumonia: infection of the lung tissue and alveoli compromising respiratory function Bronchiolitis: is inflammation of the smaller airways (bronchioles), typically presenting in young children

Answer 144

usually due to viruses such as rhinovirus, influenza, parainfluenza and coronavirus amongst others. The less common bacterial cases are caused by similar pathogens to those causing pneumonia.

Answer 145

usually bacterial in aetiology. Streptococcus pneumoniae is the most common cause, in addition to Haemophilus influenzae, Staphylococcus aureus, group A streptococci, Moraxella catarrhalis and atypicals. Viruses such influenza, respiratory syncytial virus and coronavirus can also cause pneumonia.

Answer 146

Cough is usually the main presenting symptom. Patients may also experience: Breathlessness Wheeze Pleuritic pain Fever Elderly people and children may have atypical presentations. People with pneumonia often appear more unwell than bronchitis alone.

Answer 147

wheeze, rhonchi, mild systemic features

Answer 148

appear more unwell, focal chest signs, consolidation, abnormal observations

Answer 149

FBC, U&E's, CRP, LFT's, ABG/VBG Chest X-ray if appears septic: lactate, urine output, blood cultures sputum culture if moderate-severe consider pneumococcal and legionella urinary antigen tests Do an arterial blood gas if oxygen saturations below 92%

Answer 150

CURB-65 - used to stratify mortality risk

Answer 151

Confusion (reduced AMTS) Urea >7.0mmol/l Respiratory rate ≥30 breaths/min Blood pressure (systolic) <90mmHg =/<60 diastolic 65 years old or over

Answer 152

sepsis six

Answer 153

0-1: low risk 2: intermediate risk 3-5: high risk (for CRB-65, take 1 point off these thresholds) Use this, combined with clinical judgement, when deciding whether to admit.

Answer 154

Unless very unwell, this can usually be managed as an outpatient. Patients can be advised to try over-the-counter remedies, stop smoking if applicable and safetynetted for worsening or persistent symptoms. Antibiotics, typically doxycycline, can be considered if a person's CRP is over 100mg/l or if the person is over 65 years and/or has comorbidities, or they appear unwell. A delayed antibiotic presription may be given if the CRP is over 20mg/l.

Answer 155

Acute bronchitis is usually mild & self-limiting, although the cough may persist for up to 6 months. Acute bronchitis may be complicated by development of pneumonia.

Answer 156

Pleural effusion, empyema or abscess formation Acute respiratory distress syndrome Sepsis, disseminated infection

Answer 157

Pneumonia is an inflammatory condition of the lung parenchyma caused by infection. Alveoli become filled with inflammatory cells and microorganisms, leading to consolidation of the lung tissue. This impairs gas exchange and can lead to hypoxia.

Answer 158

Streptococcus pneumonia, followed by Haemophilus influenzae and Moraxella catarrhalis - these are typical pneumonias

Answer 159

Atypical pneumonias have a variety of atypical features, e.g. a more insidious onset, extra-pulmonary symptoms such as headache and varying appearances on chest imaging.

Answer 160

Mycoplasma pneumoniae, Legionella pneumophila and Chylmydophila psittaci

Answer 161

defined as pneumonia that started 48 hours or longer after admission

Answer 162

Gram negative organisms such as Pseudomonas aeruginosa, as well as Staphylococcus aureus are more common in these environments.

Answer 163

Usually a cavitating pneumonia affecting the upper lobes presenting with red-currant sputum. It is caused by a gram-negative anaerobic rod. Increased risk in the immunocompromised, elderly and in alcohol excess.

Answer 164

A bilateral cavitating bronchopneumonia due to staphylococcal aureus, a gram-positive cocci found in clusters. Commoner in intravenous drug users, elderly patients, or as a superadded bacterial infection in those with influenza.

Answer 165

Presents with flu-like symptoms of arthralgia, myalgia, dry cough and headache. Primarily affects younger patients. Associated with an autoimmune haemolytic anaemia caused by cold agglutinins - look for low haemoglobin and high reticulocyte count - Positive cold direct Coomb’s test May lead to erythema multiforme (target-shaped rash), Stevens-Johnson syndrome, Guillain-Barre syndrome and meningoencephalitis. Best investigation is serology

Answer 166

Fever, myalgia and malaise followed by dyspnoea and a dry cough are typical presenting features. Caused by a Gram-negative bacillus Occurs in those exposed to contaminated water e.g. in humidifiers or cooling systems. Typically causes hyponatraemia and deranged liver function tests. Definitve investigation is a Urinary antigen enzyme immunoassay test

Answer 167

An intracellular bacteria acquired from contact with infected birds such as parrots. Features include lethargy, arthralgia, headache, anorexia, dry cough and fever.

Answer 168

CURB-65 0 - 0.7% CURB-65 1 - 3.2% CURB-65 2 - 13% CURB-65 3 - 17% CURB-65 4 - 41.5% CURB-65 5 - 57%

Answer 169

A CURB-65 score of 0-1 requires home treatment, 2 should consider hospital admission, 3-5 admit to hospital and consider ITU referral.

Answer 170

Fever Malaise Rigors Cough Purulent sputum Pleuritic chest pain Haemoptysis

Answer 171

Tachypnoea Tachycardia Hypotension Cyanosis Pyrexia Dullness to percussion over the consolidated area Increased vocal resonance/ tactile vocal fremitus over the consolidated area Bronchial breathing over the consolidated area Pleural rub may be heard due to inflammation of the adjacent pleura

Answer 172

Bedside: Sputum for microscopy, culture and sensitivity Consider arterial blood gas if hypoxaemic Urinary legionella and pneumococcal antigens ECG to look for complications e.g. atrial fibrillation

Answer 173

Blood cultures if febrile FBC and CRP for inflammatory markers U&Es to look for an AKI LFTs may be deranged e.g. in Legionella, baseline important when giving antibiotics Mycoplasma serology if atypical pneumonia suspected HIV testing should be offered to all patients with recurrent pneumonia (and all patients in a high prevalence area such as London)

Answer 174

Chest X-ray: may show lobar consolidation or bilateral consolidation in atypical infections, parapneumonic effusions may also be seen. CT chest may be indicated in some cases (e.g. suspected underlying malignancy, suspicious findings on X-ray)

Answer 175

Oxygen if low saturations IV fluids if dehydrated Analgesia for myalgia or chest pain Escalate for respiratory support (e.g. continuous positive airway pressure or intubation and ventilation) if patients are severely unwell - consider escalation status and patient wishes

Answer 176

Amoxicillin ± a macrolide are first-line Oral antibiotics for patients managed in the community (e.g. amoxicillin 500mg three times a day for 5 days) IV antibiotics for those admitted with more severe pneumonia (e.g. co-amoxiclav and clarithromycin) Different regimens are indicated for those with penicillin allergies and local guidelines should be consulted Antibiotics should be tailored to antimicrobial sensitivities when these are resulted

Answer 177

to screen for an underlying lung cancer (as this may be masked on initial imaging by infective changes).

Answer 178

A worsening respiratory condition with increasing tachypnoea, decreasing oxygen saturations, and new-onset bronchial breath sounds

Answer 179

Symptoms include exertional dyspnoea, dry cough, and cachexia, as evidenced by bilateral infiltrates on chest X-ray. Intravenous drug use and HIV infection are significant risk factors for developing it. exertional desaturation = pneumocystis pneumonia To investigate do a silver stain

Answer 180

herpes labialis (cold sores).

Answer 181

Haemophilus Influenzae, a gram-negative coccobacillus

Answer 182

A high fever, productive cough with rust-coloured sputum, and shortness of breath

Answer 183

Empyema is the term given for the complication of pneumonia where a collection of pus forms within the pleural space. They tend to present as either failure to recover fully with antibiotics alone or with a characteristic "swinging fever" as seen in this question. They need to be treated with surgical drainage

Answer 184

right middle lobe is the part of the lung between the horizontal fissure and oblique fissure

Answer 185

Flucloxacillin

Answer 186

Patients with community-acquired pneumonia being treated with clarithromycin should temporarily discontinue statin therapy due to an increased risk of myopathy caused by drug interactions.

Answer 187

the recommended first-line treatment options for hospital-acquired pneumonia include meropenem or piperacillin/tazobactam. These antibiotics are effective against the most common pathogens that cause hospital-acquired pneumonia, including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). Piperacillin/tazobactam is usually used as the first-line treatment with meropenem reserved for patients with penicillin allergies.

Answer 188

An upper respiratory tract infection (URTI) is a usually viral infection that causes inflammation of the upper airways, referred to as a "cold".

Answer 189

Coronaviruses Adenoviruses Enteroviruses Respiratory syncytial virus Metapneumovirus Influenza viruses

Answer 190

rhinoviruses

Answer 191

Coryza (which may manifest as rhinorrhoea, nasal congestion and loss of smell) Sneezing Cough Sore throat (may be erythematous on examination) Low-grade fever Malaise Headache Hoarse voice Conjunctival injection

Answer 192

In patients admitted to hospital, nasal and/or throat swabs may be done for viral assays or polymerase chain reaction (PCR) tests for common viruses. This allows appropriate isolation of infectious patients and rules out differentials such as COVID-19 or influenza that have specific treatments indicated.

Answer 193

Adequate fluid intake Rest Vapour rubs (e.g. Vicks) Inhaling steam or using nasal saline drops to help with nasal congestion Lozenges or analgesic sprays for sore throat Simple analgesia (paracetamol/ibuprofen) for fevers or pain Intranasal congestants should be used in the short term only as these can cause rebound symptoms if used chronically Prevent spread with good hand-hygeine, avoid sharing towels etc. Safety net people to seek medical advice if symptoms continue to worsen or are not improving beyond 10 days

Answer 194

Acute otitis media is common in young children and presents with worsening ear pain Sinusitis may occur and is characterised by facial pain and tenderness with ongoing nasal congestion Exacerbations of COPD or asthma may be triggered by URTIs Pneumonia or other superadded bacterial infections may occur, especially in vulnerable patients such as smokers, those who are immunosuppressed or elderly or have comorbidities

Answer 195

URTIs are in general mild and self-limiting conditions They generally resolve over around a week in adults or up to 2 weeks in children Symptoms typically peak over 2-3 days Some symptoms (especially cough) may continue for several weeks

Answer 196

Lung cancer refers to a primary malignancy arising from the lung parenchyma or the bronchi

Answer 197

Cancers are classified as small cell (SCLC) or non-small cell (NSCLC), with 80% being non-small cell. The main histological subtypes of NSCLC are squamous cell cancers and adenocarcinomas.

Answer 198

Tobacco smoking (e.g. cigarettes, pipes, cigars) Passive smoke exposure Occupational exposures (e.g. beryllium, cadmium, arsenic, asbestos, silica) Radon exposure Family history of lung cancer Radiation to the chest (e.g. in lymphoma treatment) Air pollution Immunosuppression (e.g. HIV, medications) Increasing age

Answer 199

neuroendocrine cells of the lung

Answer 200

alveolar type 2 epithelial cells

Answer 201

basal epithelial cells

Answer 202

Come from a variety of epithelial cells

Answer 203

sarcomatoid or salivary gland-type lung cancers

Answer 204

This can then be used to classify lung cancers into stage 1 to 4, where stage 1 is localised and small (under 4cm), stages 2 and 3 are locally advanced and stage 4 is metastatic.

Answer 205

Persistent cough Haemoptysis Dyspnoea especially on exertion Chest pain Weight loss Recurrent chest infections, or infections resistant to treatment Anorexia

Answer 206

Cachexia Finger clubbing Lymphadenopathy (supraclavicular or persistent cervical) If there is lung collapse due to an obstructing tumour - absent breath sounds, trachea deviated towards side of collapse If there is a malignant pleural effusion - stony dull on percussion, decreased breath sounds over affected area

Answer 207

Cushing syndrome, Syndrome of inappropriate ADH secretion, Lambert-Eaton myasthenia syndrome, humeral hypercalcaemia of malignancy hypertrophic pulmonary osteoarthropathy

Answer 208

usually SCLC producing ectopic ACTH, presents with dorsal cervical fat pads, truncal obesity, hypertension, striae and proximal muscle weakness

Answer 209

usually SCLC, present with symptoms of hyponatraemia e.g. fatigue, nausea, weakness, confusion or seizures

Answer 210

usually SCLC, due to autoantibodies to presynaptic calcium channels at the neuromuscular junction develop proximal muscle weakness that improves with repeated movement, as well as autonomic effects such as dry mouth, lightheadedness, constipation, urinary symptoms and erectile dysfunction Ptosis and double vision can also occur in LEMS. LEMS is caused by voltage-gated calcium channel antibodies

Answer 211

usually squamous cell carcinomas (SCC) that release parathyroid hormone-related protein (PTHrP) that mimics PTH and causes hypercalcaemia, leading to symptoms of bone pain, constipation, anorexia, abdominal pain, excessive thirst and confusion

Answer 212

usually adenocarcinomas or squamous cell carcinoma which cause a periosteal reaction of bones, resulting in clubbing and arthritis especially affecting wrists and ankles

Answer 213

Aged 40+ with unexplained haemoptysis Chest X-ray findings suspicious for lung cancer

Answer 214

done for patients aged 40+ who have one of these symptoms and have ever smoked (or two symptoms if they are never smokers): Cough Fatigue Shortness of breath Chest pain Weight loss Anorexia Also An urgent chest X-ray should be considered in patients aged 40+ with any of: Persistent/recurrent chest infection Finger clubbing Supraclavicular or persistent cervical lymphadenopathy Thrombocytosis Chest signs consistent with lung cancer (e.g. reduced breath sounds, dullness to percussion)

Answer 215

Lung mass (may be rounded or spiculated, squamous cell carcinomas may cavitate) Consolidation (where there is infection downstream of the tumour obstructing an airway) Bulky hilum (especially squamous cell carcinomas which often arise centrally) Lobar collapse (due to bronchial obstruction, especially squamous cell carcinomas) Pleural effusion

Answer 216

Sputum cytology - low sensitivity but may be of use in patients who decline or cannot have a biopsy Diagnostic thoracocentesis - i.e. a pleural tap; if a pleural effusion is present this should be done and the fluid sent for cytology as well as cell count, microscopy, culture, glucose, LDG and protein (to determine whether it is a transudate or exudate) Blood tests - including FBC for anaemia and thrombocytosis, U&Es for hyponatraemia and baseline renal function, LFTs for baseline liver function (may be deranged in liver metastases), bone profile for hypercalcaemia, CRP for superadded infection, clotting if interventions planned CT chest with contrast - should be done after chest X-ray to better characterise any lesion seen and investigate for local spread Biopsy - to confirm the diagnosis and subtype of cancer, may be done percutaneously for peripheral tumours or via bronchoscopy for central masses

Answer 217

Spirometry - to assess lung function to determine if a patient is suitable for surgical intervention CT chest abdomen and pelvis - to stage the cancer (determine if there are any metastases) PET-CT scan - a more sensitive way to stage the cancer and look for local or distant spread CT or MRI head - may be done as part of staging investigations if curative treatment is planned, or if there are symptoms suspicious of intracranial metastases

Answer 218

Holistic support and an MDT approach (e.g. clinical nurse specialist involvement, palliative care input for troubling symptoms or end of life care, signpost to support e.g. Macmillan groups) Smoking cessation Discussions around advance care planning where appropriate

Answer 219

first line in most cases of small cell lung cancer and stage 3 or 4 non-small cell lung cancer - this is with palliative intent (i.e. not aiming to cure the disease but to prolong life and improve symptoms). It is also offered to some patients prior to (neoadjuvant) or after (adjuvant) curative surgery.

Answer 220

used especially in advanced non-small cell lung cancer; this includes medications such as pembrolizumab or atezolizumab (again with palliative intent).

Answer 221

exist for patients with specific mutations, e.g. erlotinib for patients with advanced non-small cell lung cancers with EGFR-TK mutations.

Answer 222

may be curative (for example in early non-small cell lung cancer) or palliative - it is often combined with chemotherapy or other treatment modalities.

Answer 223

Supportive therapies include analgesia, oxygen if hypoxic and opioid treatment for breathlessness.

Answer 224

Lobectomy is the standard curative therapy for early stage lung cancers (which can be open or thoracoscopic in approach). Some small tumours can be removed with a wedge resection. More extensive surgery such as a pneumonectomy (removal of a lung) may be required depending on the size and location of the tumour, however patients need to have adequate FEV1 on pre-operative spirometry to be appropriate for surgery (over 2L for a pneumonectomy). All patients undergoing surgery should also have mediastinal and hilar lymph nodes sampled (to look for metastases) or resected (removed) to reduce the chances of recurrence.

Answer 225

Lymph nodes Liver - this can cause significant pain due to stretching of the liver capsule Brain - may cause nausea and vomiting, headaches, seizures, personality changes, sensory or motor symptoms, dysphasia or cerebellar symptoms, depending on where in the brain is affected Bones - mostly osteolytic metastases, can cause bony pain and pathological fractures; there is a risk of metastatic spinal cord compression with vertebral metastases Adrenal glands - may cause flank pain and adrenal insufficiency The contralateral lung or elsewhere in the ipsilateral lung The most common site is brain for metastases

Answer 226

horner’s syndrome - due to an apical (Pancoast) tumour, causes ipsilateral anhidrosis, miosis and partial ptosis - cervical sympathetic plexus Superior vena cava obstruction (SCVO) - lung cancer is the commonest cause of SCVO, causing symptoms of breathlessness, dizziness, headache and swelling of the face, neck and arms. This is a medical emergency due to the risk of airway obstruction. Malignant pleural effusion Hoarse voice - secondary to invasion of left recurrent laryngeal nerve Persistent lower respiratory tract infection due to obstructing tumour Raised hemidiaphragm secondary to invasion of phrenic nerve Brachial plexus injury secondary to tumour invasion from a Pancoast tumour

Answer 227

periostitis (inflammation of the periosteum, the connective tissue layer surrounding bone), digital clubbing and painful arthropathy of large joints are present in the history

Answer 228

The cells have dense neurosecretory granules

Answer 229

adenocarcinoma

Answer 230

Mesothelioma classically manifests in the pleura, rather than the lung itself like most other forms of lung cancers. The pleura thickens and some areas become plaque like due to continued proliferation.

Answer 231

surgical intervention, specifically lobectomy, is the primary definitive management for optimal outcomes. Lobectomy (with hilar and mediastinal lymph node resection/sampling) is first-line treatment for those with stage I or II cancer who are medically fit for surgery. This surgery is done with curative intent. NSCLC

Answer 232

Radiotherapy: Is first-line for those with stage I-III disease who are not suitable for surgery. This treatment is given with curative intent.

Answer 233

Chemotherapy First line regimes use a combination of: Third-generation chemotherapy agent: e.g. docetaxel, paclitaxel or gemcitabine Platinum agent: e.g. carboplatin or cisplatin

Answer 234

Adjuvant chemotherapy should be offered to patients who have undergone a complete resection Adjuvant radiotherapy is offered to patients who have had a incomplete resection of their tumour All patients with stage I-III disease who are not suitable for surgery should be considered for chemoradiotherapy

Answer 235

First line treatment involves: 4-6 cycles of Cisplatin-based combination chemotherapy Concurrent or adjunct thoracic radiotherapy is only considered if there has been a good response to chemotherapy

Answer 236

First line treatment involves: Platinum-based combination therapy where the patient is reassessed for a response after each cycle (up to a maximum of 6 cycles) Concurrent or adjunct thoracic radiotherapy can be considered if there has been a good response to chemotherapy at both the primary and metastatic sites.

Answer 237

For all stages of SCLC second-line therapy can be considered in those who have relapsed. This includes: Further chemotherapy (maximum 6 cycles) Palliative radiotherapy to control local symptoms

Answer 238

Immediate oral dexamethasone 8mg

Answer 239

Confirmed by the positive Pemberton's sign. This is when a patient raises both hands above their head causing facial plethora, venous congestion and respiratory distress. Sitting the patient upright and providing oxygen may provide symptomatic relief. Dexamethasone can be administered to reduce swelling and therefore the pressure on the SVC

Answer 240

Occupational lung disease encompasses a variety of respiratory disorders caused by inhalation of dust, chemicals, or proteins in the workplace

Answer 241

Conditions such as pneumoconiosis, occupational asthma, and hypersensitivity pneumonitis are included under this umbrella term. Pneumoconiosis is induced by mineral dusts like silicosis from silica exposure and asbestosis from asbestos exposure. Occupational asthma, triggered by irritants like isocyanates or grain dust, is the most common work-related lung disease in developed countries. Hypersensitivity pneumonitis results from an immune response to inhaled organic antigens or low molecular weight agents. Chronic obstructive pulmonary disease (COPD) can also be work-related, particularly in smokers exposed to fumes and dust. Mesothelioma and lung cancer are severe potential outcomes related to asbestos exposure

Answer 242

dusts, gases and fumes, biological agents, and radiation

Answer 243

Silica: Workers in mining, quarrying, construction and ceramic industries are at increased risk of developing silicosis due to inhalation of silica dust. Coal: Coal workers' pneumoconiosis (CWP) is associated with coal mining. Asbestos: Asbestosis is predominantly seen in individuals involved in asbestos mining, shipbuilding, roofing and plumbing.

Answer 244

Sulphur dioxide: It is commonly encountered in industries related to burning of fossil fuels such as power plants. Nitrogen oxides: These are produced during high-temperature combustion processes like welding. Ozone: Workers involved in photocopying or welding are at risk due to ozone exposure.

Answer 245

Moulds and fungi: Occupations involving agriculture, forestry or gardening present a risk for hypersensitivity pneumonitis due to exposure to moulds or fungi. Bacteria or animal proteins: Workers exposed to water aerosols (e.g., air conditioning systems), or those handling animals may develop extrinsic allergic alveolitis.

Answer 246

Lung cancer risk increases significantly with exposure to radon gas in uranium miners and millers. This risk is further amplified in smokers.

Answer 247

Trigger an inflammatory response with inflammation and fibrosis leading to tissue remodelling

Answer 248

dose-response relationship, duration of exposure, individual susceptibility, presence of pre-existing lung disease and smoking status

Answer 249

Pneumoconioses: These are caused by the inhalation of inorganic dusts. They include asbestosis (asbestos), silicosis (silica), coal worker's pneumoconiosis (coal dust) and berylliosis (beryllium). Organic Dust Diseases: Resulting from exposure to organic materials such as moulds, spores or proteins. Examples include farmer's lung (mouldy hay), bird fancier's lung (bird proteins) and malt worker's lung (malt dust).

Answer 250

Inhalation fever syndromes: Caused by acute high-level exposures to certain agents like metal fume fever (metal oxides) and polymer fume fever (polytetrafluoroethylene). Toxic pneumonitis: Occurs due to chronic low-level exposure causing inflammation of the lungs. Examples include chlorine gas, ammonia, sulfur dioxide.

Answer 251

Hypersensitivity Pneumonitis: This is an allergic reaction to inhaled substances leading to inflammation in the alveoli. It includes extrinsic allergic alveolitis, which itself has several subtypes such as farmer’s lung or bird fancier’s lung.

Answer 252

Lung cancer: Occupational exposure to certain substances like asbestos, radon, chromium, nickel and coal products can increase the risk of developing lung cancer. Mesothelioma: A rare form of cancer that affects the pleura. It is strongly associated with asbestos exposure.

Answer 253

Tuberculosis: Particularly common in healthcare workers or those working in close contact with affected patients. Anthrax: Associated with handling infected animal products.

Answer 254

Cough: This is often the first symptom to develop. It may be dry or productive, depending on the nature of the disease. Dyspnoea: Shortness of breath is another common symptom that may occur at rest or during physical exertion. Chest tightness or pain: These symptoms may be present, especially in cases involving pleural disease. Sputum production: In some cases, patients may produce sputum which can vary in colour and consistency based on the underlying condition.

Answer 255

Pulmonary function tests (PFTs): These can show restrictive or obstructive patterns, reduced diffusion capacity and other abnormalities that point towards specific conditions such as pneumoconiosis or occupational asthma. Radiographic findings: Chest X-rays or CT scans can show nodular infiltrates, fibrosis, pleural thickening or other changes consistent with occupational lung diseases. Laboratory investigations: Certain blood tests may show raised inflammatory markers. Bronchoalveolar lavage (BAL) and biopsy might be required for definitive diagnosis in some cases. Occupational history: A detailed occupational history is crucial to identify potential exposure to harmful substances. This includes the type of work, duration of exposure, use of protective equipment and any previous respiratory problems.

Answer 256

early diagnosis, patient education, symptom management, reducing exposure, supportive care

Answer 257

Pulmonary Fibrosis: This is a common complication that results from the deposition of excess fibrous connective tissue (fibrosis) in the lungs. It leads to stiffening or scarring of lung tissue which impairs oxygen uptake. Chronic Obstructive Pulmonary Disease (COPD): Patients with occupational lung disease are at an increased risk for developing COPD, characterised by chronic bronchitis and emphysema. This results in progressive airflow limitation and reduced respiratory capacity. Lung Cancer: Certain occupational exposures such as asbestos, silica dust, diesel exhaust, and certain gases can significantly increase the risk of developing lung cancer. Pleural Disease: Asbestos exposure is also associated with pleural conditions including pleural effusion, diffuse pleural thickening, pleural plaques and malignant mesothelioma. Hypoxemia: Chronic inflammatory changes can impair gas exchange leading to hypoxemia - a decrease in arterial blood oxygen levels. This may result in cor pulmonale if untreated. Cor Pulmonale: Chronic hypoxemia can lead to right-sided heart failure or cor pulmonale due to increased resistance in the pulmonary circulation.

Answer 258

Asymptomatic, COPD, May lead to progressive massive fibrosis

Answer 259

- Exertional SOB - Cough +/- black sputum upper lobe fibrosis, restrictive pattern

Answer 260

Fibrotic lung disease caused by inhalation of silica TB - Stonemason - Pottery - Ceramics ‘Egg shell’ calcification of hilar lymph nodes

Answer 261

A pneumothorax refers to a collection of air in the pleural cavity (space between the visceral and parietal pleura) which may cause collapse of the underlying lung parenchyma.

Answer 262

They may be spontaneous or traumatic (including iatrogenic causes). Spontaneous pneumothoraces can be further divided into primary pneumothoraces (in patients without an underlying lung disease) and secondary (in patients with underlying lung diseases such as COPD or asthma).

Answer 263

A tension pneumothorax occurs when the defect in the pleura that has led to the pneumothorax creates a one-way valve effect whereby air can enter the pneumothorax but not leave it. - This causes the pneumothorax to progressively expand, putting pressure on the heart and great vessels and causing mediastinal shift - This is a medical emergency that rapidly leads to cardiac arrest if untreated

Answer 264

Sudden onset shortness of breath Pleuritic chest pain Dry cough Tachypnoea and increased work of breathing The following signs will be found on the affected side of the chest: Unilateral reduced expansion Unilateral hyper-resonance to percussion Reduced or absent breath sounds Reduced vocal resonance or tactile vocal fremitus

Answer 265

Patients with a tension pneumothorax may also have: Tracheal deviation to the contralateral side Tachycardia Hypotension Distended neck veins

Answer 266

Patients with a suspected tension pneumothorax should be diagnosed and treated with needle decompression based on the clinical picture, with no delay for investigations. For other patients, an erect PA chest X-ray is diagnostic.

Answer 267

CT chest should be used in high-risk patients where it is not clear from the chest X-ray whether it is safe to place a chest drain.

Answer 268

If a tension pneumothorax is suspected, emergency management is to decompress this by inserting a large-bore cannula into the second intercostal space on the affected side, or fifth intercostal space if a traumatic cause is suspected, as per ATLS guidelines. If this fails, open thoracostomy should be done immediately After initial emergency decompression, a chest drain should be inserted

Answer 269

Conservative management involves no intervention for the pneumothorax, and patients are monitored to ensure they do not deteriorate and any symptoms resolve

Answer 270

Ambulatory devices (e.g. pleural vents) are one-way valves which allow air to leave the pneumothorax but not re-enter it - They can be inserted in a simple procedure under local anaesthetic - Patients can then be followed up as outpatients

Answer 271

chest drain and admission for monitoring

Answer 272

management depends on their priorities - Conservative management allows avoidance of any procedure - Both needle aspiration and ambulatory devices offer more rapid symptomatic relief (ambulatory device insertion may not be available in all hospitals)

Answer 273

All patients should be reviewed in an outpatient clinic 2–4 weeks after presenting with a pneumothorax (with repeat chest imaging) Patients should be advised on smoking cessation if relevant Advise patients not to fly until 7 days after chest imaging has confirmed resolution of the pneumothorax Advise patients they should not take part in underwater diving for life (except in rare cases where they have been treated with bilateral open surgical pleurectomy)

Answer 274

should be considered for early discussion with cardiothoracic surgery for possible video-assisted thoracic surgical repair.

Answer 275

results in less ventilation and a lower V/Q ratio

Answer 276

Fluid swinging A patent chest drain allows fluid to move synchronously with respiratory pressure changes within the thorax.

Answer 277

an ongoing air leak

Answer 278

Type 1 respiratory failure (T1RF) is defined as hypoxaemia (PaO2<8kPa) with low or normal levels of carbon dioxide in the arterial blood.

Answer 279

Type 2 respiratory failure (T2RF) is defined as hypoxaemia (PaO2<8kPa) with hypercapnia (PaCO2>6.5kPa).

Answer 280

V/Q mismatch Diffusion Limitation Shunting

Answer 281

The commonest cause of T1RF An imbalance in ventilation versus perfusion of the lungs leading to inefficient oxygenation A low V/Q occurs when alveoli are not sufficiently ventilated e.g. in airways disease A high V/Q occurs when there is limited blood flow in the lungs e.g in pulmonary embolism

Answer 282

Impaired gas exchange across the alveolar membrane May be due to inflammation or fibrosis of the membrane e.g. in idiopathic pulmonary fibrosis May be due to a decrease in the available surface area for diffusion e.g. emphysema Carbon dioxide is more soluble than oxygen hence why hypoxaemia is commonly seen without hypercapnia

Answer 283

Refers to blood that passes through the lungs without undergoing gas exchange May be a physiological response to V/Q mismatch as if there are alveoli with very poor ventilation the blood that goes to them will not be ventilated Anatomical shunting may be seen e.g. in pulmonary arteriovenous malformations Can also cause hypercapnia and T2RF if severe

Answer 284

Increase in dead space Reduced minute ventilation

Answer 285

Dead space is ventilated but not perfused and so there is no gas exchange There is always some anatomical dead space e.g. the airways There may also be dead space in unperfused alveoli This alveolar dead space increases if capillaries are destroyed e.g. in emphysema or interstitial lung disease

Answer 286

Minute ventilation is the total amount of air entering the lungs per minute If it decreases, there is a decrease in alveolar ventilation It is equal to respiratory rate x tidal volume Conditions that reduce respiratory rate include respiratory depressants such as alcohol or opiate medications Conditions that reduce tidal volume include neurological disorders such as motor neuron disease or chest wall deformities

Answer 287

Dyspnoea Headache Light-headedness Confusion Drowsiness Agitation Symptoms related to underlying cause e.g. productive cough and fever in pneumonia

Answer 288

Tachypnoea (although respiratory rate may be low in some cases of T2RF e.g. opiate overdose) Cyanosis Accessory muscle usage Nasal flaring Signs of central nervous system dysfunction e.g. reduced GCS, irritability Signs related to underlying cause e.g. wheeze in a COPD exacerbation Signs related to hypercapnia (i.e. T2RF only): Flushed skin Bounding peripheral pulses Asterixis Tachycardia or arrhythmia Drowsiness

Answer 289

Arterial Blood gas

Answer 290

In chronic T2RF, a longstanding respiratory acidosis is compensated for by an increase in bicarbonate above the normal range of 22-26 mmol/L pH may therefore be normal despite a high PaCO2 e.g. COPD, neuromuscular disorders In acute T2RF, there is not time for renal compensation and bicarbonate retention Bicarbonate is normal pH is low (respiratory acidosis) e.g. acute severe asthma, opiate overdose

Answer 291

Sputum sample in suspected pneumonia or an infectious exacerbation of COPD Blood tests e.g. WCC and CRP if infection suspected Chest X-ray to investigate for infection, pneumothorax etc. CTPA if pulmonary embolism is suspected

Answer 292

Supplementary oxygen is required to correct hypoxaemia However caution is needed in patients at risk of or in T2RF as overoxygenation causes worsening hypercapnia This is multifactorial, with one important mechanism being oxygen-induced vasoconstriction increasing V/Q mismatch and dead space, decreasing CO2 clearance Because of this, patients known to be at risk of CO2 retention should have lower target oxygen saturations (usually 88-92%) Oxygen can be delivered by a variety of devices In an emergency, high-flow oxygen via a non-rebreather mask should be initiated Oxygen should then be weaned to target saturations (usually 94-98% if the patient is not known to retain CO2) Delivery may be via nasal cannulae or a face mask depending on flow rate

Answer 293

Severe T2RF may be treated with non-invasive ventilation (NIV) This is often referred to as BIPAP (Bi-level Positive Airway Pressure) This works by delivering higher pressures in inspiration and lower pressures in expiration to improve ventilation Examples of when NIV may be used include COPD with respiratory acidosis or T2RF in the context of neuromuscular disease Contraindications are the same as for CPAP Intubation and ventilation is also an option for severely unwell patients not responding to other treatments Consideration should be given to treatment escalation plans, involving the patient and their family as much as possible For example, a patient with end-stage COPD or terminal cancer may not have the physiological reserve to survive an ITU admission and so in the event that they were not responding to medical treatment +/- CPAP/NIV, a decision may be made to palliate

Answer 294

Severe T1RF may be treated with continuous positive airway pressure (CPAP) This works by splinting open the airways and alveoli by blowing air into the lungs at high flow rates via a face mask This reduces respiratory effort as well as expanding collapsed areas of the lungs (which is called "recruitment") Examples of when CPAP may be used include pneumonia and pulmonary oedema Contraindications include confusion, vomiting (due to aspiration risk) or untreated pneumothorax (as CPAP would worsen this by blowing more air into it)

Answer 295

A decline in lung function after recovery from the acute illness Hypoxic ischaemic injury to other organs (e.g. the brain) Cor pulmonale Polycythaemia Death

Answer 296

Mask leak Pressure sores from tight-fitting masks Hypotension Aspiration (due to gastric inflation) Pneumothorax Epistaxis

Answer 297

Dental injury during intubation Barotrauma (pressure-induced trauma to the lungs) Ventilator-associated pneumonia Tracheomalacia Complications of immobility (e.g. venous thromboembolism, pressure ulcers)

Answer 298

Sarcoidosis is a multi-system disease that is characterised by the formation of non-caseating granulomas around the body. This leads to inflammation and scarring in the organs affected, most commonly the lungs and skin. Other organs affected include the nerves, the brain, the heart, the liver and the eyes.

Answer 299

Dry cough Dyspnoea Reduced exercise tolerance Chest pain Clubbing Fine crackles on auscultation

Answer 300

Erythema nodosum (inflammation of subcutaneous fat leading to tender nodules especially on the shins) Lupus pernio (red/purple plaques and nodules on the face) Hyper or hypopigmentation of the skin

Answer 301

Meningitis Peripheral neuropathy Facial nerve palsy (may be bilateral) Headache Seizures/encephalopathy

Answer 302

Uveitis Keratoconjunctivitis sicca Glaucoma

Answer 303

Arrhythmias Restrictive cardiomyopathy Syncope

Answer 304

Fatigue Weight loss Arthralgia Low-grade fevers Lymphadenopathy Enlarged parotid glands

Answer 305

a type of acute sarcoidosis Fever Polyarthralgia Erythema nodosum Bilateral hilar lymphadenopathy (seen on chest X-ray)

Answer 306

Fever Uveitis Parotid swelling Facial nerve palsy

Answer 307

ECG looking for arrhythmias or changes related to hypercalcaemia (e.g. QT shortening) Mantoux test looking for evidence of exposure to tuberculosis (an important differential) Lung function testing - if pulmonary sarcoidosis suspected Ophthalmological examination if ocular sarcoidosis suspected

Answer 308

FBC may show lymphopenia, anaemia or raised white cells LFTs for liver disease Renal function for renal impairment (not common in sarcoidosis) Bone profile for hypercalcaemia ESR may be raised due to chronic inflammation Serum ACE is elevated in around 60% and normalises if the disease resolves (with or without treatment)

Answer 309

Chest x-ray to stage sarcoidosis High resolution CT chest scan PET scanning Echocardiogram

Answer 310

Stage 1 - Bilateral hilar lymphadenopathy (BHL) Stage 2 - BHL with peripheral infiltrates Stage 3 - Peripheral infiltrates alone Stage 4 - Pulmonary fibrosis

Answer 311

Biopsy is required to confirm the diagnosis in most cases (with a classic presentation of chronic pulmonary disease or a clear case of Lofgren's syndrome being exceptions) - this is looking for the classic finding of noncaseating granulomas Bronchoalveolar lavage may also be done in suspected pulmonary sarcoidosis, with classic findings of raised lymphocytes and an elevated CD4/CD8 ratio

Answer 312

Patient education and support Smoking cessation No active treatment is needed in many cases of sarcoidosis

Answer 313

Steroids e.g. oral prednisolone with a higher dose at induction which is then reduced to a lower maintenance dose Second line immunosuppressants (e.g. if steroids contraindicated or not effective) include methotrexate, mycophenolate or azathioprine Third line treatment is usually with biologics (e.g. infliximab)

Answer 314

Medical treatment should be started only if sarcoidosis symptoms are affecting quality of life or there is significant risk of morbidity or mortality from sarcoidosis

Answer 315

Rarely in severe cases of pulmonary sarcoidosis a lung transplant may be considered In cases of pulmonary sarcoidosis complicated by aspergilloma, surgical management of haemoptysis is sometimes required

Answer 316

Pulmonary fibrosis (stage IV pulmonary sarcoidosis Cor pulmonale Pulmonary hypertension Aspergillomas can form in cavities left by granulomatous pulmonary disease Arrhythmias and sudden death in cardiac sarcoidosis Low mood and anxiety Complications of long-term steroid use (e.g. osteoporosis, hyperglycaemia)

Answer 317

Tuberculosis (TB) refers to infection with the Mycobacterium tuberculosis bacterium. It usually affects the lungs, but can infect multiple other organ systems. Patients may have latent TB which means that they are infected but have no symptoms and are not contagious, or active TB. TB transmission is usually via inhalation of infected droplets which are produced when someone with active TB coughs, sneezes or spits.

Answer 318

HIV increases the risk of TB by 16 times, and TB is the leading cause of death amongst people with HIV; all patients diagnosed with TB should be offered a HIV test Other forms of immunosuppression increase the risk of infection and of reactivation of latent TB; patients on medications such as infliximab, azathioprine and ciclosporin are particularly at risk and should be screened for TB before starting these Close contacts of infected patients - household members of someone with active TB have a 1 in 3 risk of infection, however other close contacts (including healthcare workers) are also at increased risk Being from a high-risk country - countries with high rates of TB include India, Pakistan, Romania, Somalia and Eritrea Homelessness - strongly related to other risk factors such as overcrowding, malnutrition, drug and alcohol abuse and recent stays in prison Children have a greater risk of infection although this is usually latent Elderly patients have an increased risk of TB reactivation due to immune senescence

Answer 319

Mycobacterium tuberculosis is a type of aerobic, slow growing bacteria. They are described as acid fast bacilli, which means they are resistant to acid staining.

Answer 320

If active disease develops immediately, this is called 'primary TB'

Answer 321

In some cases this primary infection disseminates widely via the bloodstream - this is known as miliary TB due to the characteristic pattern on chest X-ray when re-infection of the lungs occurs via circulating bacteria

Answer 322

If latent disease later becomes active (e.g. if a patient becomes immunosuppressed), this is referred to as a 'reactivation of TB' which may be in the lungs or at distant sites

Answer 323

Night sweats Fevers Weight loss Malaise Lymphadenopathy lymph nodes are typically enlarged and non-tender may form sinus tracts if chronic cervical and supraclavicular nodes are most commonly affected

Answer 324

Chronic productive cough Haemoptysis Shortness of breath Collapse or pleural effusion leading to dullness on percussion and reduced breath sounds over the affected area

Answer 325

Meningitis causing headaches and meningism Focal neurological signs (classically cranial nerve lesions due to involvement of the basal meninges) Decreased consciousness

Answer 326

Renal TB may present with haematuria and flank pain Epididymo-orchitis may present with pain and swelling Salpingitis (TB of the fallopian tube) may cause pain and vaginal bleeding

Answer 327

Pott's syndrome (spinal TB) causes back pain, spinal deformities and neurological deficits Arthritis causes joint pain and swelling Osteomyelitis may lead to a painful 'cold abscess' with localised swelling and erythema, sometimes wiht a draining abscess Psoas abscesses may present with a classic triad of fever, limp and back pain

Answer 328

Ileocaecal TB can cause bowel obstruction with abdominal pain and constipation Ascites may result from perotineal TB Intestinal TB may mimic IBD with abdominal pain and bloody diarrhoea

Answer 329

Pericardial effusions may cause a raised JVP and pulsus parodoxus Constrictive pericarditis also causes a raised JVP and may present with signs of right-sided heart failure such as peripheral oedema and hepatic congestion

Answer 330

Erythema nodosum (tender nodules, usually on the shins) Lupus vulgaris refers to painful nodular skin lesions caused by TB, usually around the face Miliary TB may spread to the skin causing a widespread rash Scrolfuloderma is direct invasion of the skin from a TB-infected lymph node or bone, forming ulcerating and fistulating tracts from subcutaneous nodules usually around the neck area

Answer 331

TB is the leading cause of adrenal insufficiency worldwide Symptoms include fatigue, lightheadedness, nausea and abdominal pain Signs include hypotension and skin hyperpigmentation

Answer 332

Close contacts of known active TB cases Patients about to start immunosuppressant treatment such as anti-TNFa agents (as this would put them at risk of reactivation) Patients who are significantly immunocompromised (e.g. late-stage HIV, bone marrow or organ transplant recipients) NHS employees working with patients Patients arriving in the UK from a high risk area (some will have pre-screening before moving) Patients in underserved groups in high-prevalence settings e.g. homeless people, prisoners and people attending substance misuse services may also be offered screening by local TB teams as part of outreach programmes and active case finding.

Answer 333

The Mantoux test involves injecting tuberculin intradermally The person then returns after 2-3 days to assess the local skin reaction Induration of 5mm or more is considered a positive test The Interferon-gamma release assay (IGRA) test is a blood test which detects the white blood cell response to TB antigens It is quicker than the Mantoux test to perform Fewer false positives are seen with the IGRA test (e.g. it is negative in patients who have had a BCG vaccine whereas this can make the Mantoux test inconclusive) Patients with a positive screening test should be referred to TB services for further investigations and treatment.

Answer 334

Sputum samples for microscopy, culture and sensitivity testing (MCS) At least three early morning samples should be sent In patients who cannot produce sputum, broncheoalveolar lavage or sputum induction may be used Samples are stained with Ziehl-Neelsen or Auramine staining before microscopy Patients who are 'smear positive' have acid-fast bacilli seen on microscopy, which is a correlate of infectivity If microscopy is negative, culture may still be positive but this takes several weeks to return due to the slow-growing nature of myocobacteria Early morning urine sample MCS for suspected genitourinary TB This is looking for genitourinary TB Sterile pyuria (where white cells but not bacteria are seen in the urine) may indicate TB ECG may show evidence of pericardial effusion (e.g. small complexes) or pericarditis (e.g. ST changes)

Answer 335

FBC, CRP, liver and renal function to look for evidence of infection and get a baseline before starting antibiotics Mycobacterial blood MCS which may take several weeks to be resulted similarly to sputum cultures HIV testing should be offered to all patients with suspected TB

Answer 336

Chest X-ray which may show: Cavitation - most common symptom Pleural effusion Mediastinal or hilar lymphadenopathy Parenchymal infiltrates, especially in the upper lobes Miliary TB (tiny nodules throughout the lung fields) Joint or spinal X-rays if suspected skeletal involvement CT head for suspected CNS TB Ultrasound of lymphadenopathy, the genitourinary system or the abdomen Echocardiogram for suspected pericardial disease The most common CXR finding in TB is a patchy pattern of opacification, sometimes described as "fibronodular"

Answer 337

Biopsies or needle aspiration of sites of suspected extrapulmonary TB (e.g. lymph node biopsy) PCR eg. GeneXpert is a molecular test for TB which also looks for rifampicin resistance This can be performed on multiple specimen types e.g. sputum or tissue This gives rapid results and so is particularly useful if there is a high suspicion of TB Further resistance testing may be done after a diagnosis of TB is made to determine appropriate antibiotic treatment Lumbar puncture for suspected CNS TB - CSF should be sent for MCS and labelled as suspected TB

Answer 338

The BCG vaccine is a live attenuated vaccine that is given to protect against TB It also protects against leprosy and can be used to treat some bladder cancers It is not a routine part of the UK's childhood vaccination schedule but is given to babies (or children up to 16) at higher risk of TB including those who: are close contacts of a pulmonary TB case live in an area with more than 40 cases of TB per 100,000 people per year (e.g. all of London) have lived in a country with high TB rates for 3 months or more have a parent/grandparent born in a country with high TB rates It is 80% effective against severe forms of TB in childhood (e.g. meningitis) but is significantly less effective in respiratory disease Because of this, it is only offered to adults with occupational exposures (e.g. healthcare workers, vets, prison guards) It should not be given to: people with a positive Mantoux test (which should be offered to adults prior to vaccination) immunosuppressed people (because it is a live vaccine so could reactivate) people who have previously had TB

Answer 339

Options for patients with no evidence of active infection include: Three months of isoniazid, pyridoxine and rifampicin Six months of isoniazid and pyridoxine

Answer 340

Referral to the local multidisciplinary TB team for specialist management Patient education including encouraging adherence, giving information and explaining how to seek help if they experience symptoms of relapsing disease Contact tracing TB is a notifiable disease and so should be reported promptly to the local health protection team Infection control measures, for example advising patients with active pulmonary TB to wear a mask until they have completed 2 weeks of antibiotic treatment Identification of patients who may need additional support to comply with treatment (e.g. those who are homeless), for example directly observed therapy (where a key-worker observes the patient taking every dose of antibiotics) Identification of patients with multidrug and extensively drug-resistant TB

Answer 341

The standard regimen for active pulmonary TB, which is 2 months of isoniazid (with pyradoxine), rifampicin, ethambutol and pyrazinamide, followed by isoniazid (with pyradoxine) and rifampicin alone for a further 4 months Longer courses of antibiotics in TB meningitis, pericardial and spinal TB Steroids may be added in the initial weeks of antibiotic treatment for CNS and pericardial TB Multidrug-resistant TB often requires 18-24 months of treatment with at least six drugs These second-line antibiotics include amikacin, macrolides, quinolones and capreomycin

Answer 342

In selected cases of multidrug or extensively drug-resistant TB a lung resection may be considered This is either unilateral or of both lung apices Patients need adequate lung function to be eligible Some types of extra-pulmonary TB may warrant surgical treatment e.g. drainage of renal abscesses

Answer 343

Red/orange discolouration of bodily fluids CYP450 induction (i.e. reduces effectiveness of other medications such as the combined oral contraceptive pill) Hepatotoxicity

Answer 344

Peripheral neuropathy (prevented by co-administration of pyridoxine to prevent vitamin B6 deficiency) Hepatotoxicity CYP450 inhibition

Answer 345

Arthralgia Hyperuricaemia (may cause gout) Hepatotoxicity

Answer 346

Retrobulbar neuritis causing colour blindness and loss of visual acuity Visual side effects are more common in chronic kidney disease so dose adjustment may be required

Answer 347

Bronchiectasis resulting from permanent airway damage from infection and inflammation Antibiotic resistance especially in patients who have previously been treated for TB; around 10% of people diagnosed with TB in the UK have resistance to at least one of the four first line antibiotics with rifampicin resistance being commonest Onwards transmission of TB especially if untreated or there is resistance to treatment Psychosocial distress which may be exacerbated by stigma and social isolation Aspergillomas may form in cavities that may persist after TB treatment Pulmonary fibrosis may occur due to permanent lung damage from pulmonary TB Death - TB kills around 5% of people diagnosed in the UK, with significantly higher mortality in countries where there is poor access to healthcare

Answer 348

Eye-thambutol (Optic neuritis) - Isoniazid (Im-so-numb-azid) (peripheral neuropahty) - Rifampicin (red-orange-pissin) red/orange secretions

Answer 349

infliximab

Answer 350

lymphocyte predominance, low cerebrospinal fluid (CSF) glucose, high CSF protein and AFB smear positivity

Answer 351

standard treatment with rifampicin, isoniazid, pyrazinamide and ethambutol for the initial 2 months. After this, patients are treated with rifampicin and isoniazid for a further 10 months (as opposed to 4 months for patients with active tuberculosis without central nervous system involvement).