Respiratory

Question 1

What is a pleural effusion?

Answer 1

Fluid in the pleural space. Effusions can be divided by their protein concentration into transudates (less than 25g/L) and exudates (more than 35 g/L)

Question 2

What causes transudates? (4)

Answer 2

1. Increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
2. Hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
3. Hypothyroidism
4. Meigs’ syndrome (right pleural effusion and ovarian fibroma)

Question 3

What causes exudates?

Answer 3

Mostly due to increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy

Causes: pneumonia, TB, pulmonary infarction, rheumatoid arthritis, SLE, bronchogenic carcinoma, malignant metastases, lymphoma, mesothelioma, lymphangitis carcinomatosis

Question 4

What signs can be seen in a pleural effusion? (3)

Answer 4

1. Decreased expansion, stony dullness on percussion and diminished breath sounds on affected side
2. Decreased tactile vocal fremitus and vocal resonance (inconsistent and unreliable)
3. There may be tracheal deviation AWAY from effusion if large

Question 5

What investigations can be done in pleural effusions? (4)

Answer 5

1. CXR: blunting of costophrenic angles
2. US - identifies presence of pleural field and used in diagnostic/therapeutic aspiration
3. Diagnostic aspiration
4. Pleural biopsy

Question 6

How are pleural effusions managed? (3)

Answer 6

1. Treat underlying cause!
2. Drainage if effusion is symptomatic (aspiration or intercostal drain)
3. Pleurodesis with tetracycline, bleomycin or talc for recurrent effusions

Question 7

Define chronic bronchitis

Answer 7

Chronic sputum production every day for at least 3 months per year for 2 consecutive years

Question 8

What are the lung function test features of a ‘pink puffer’?

Answer 8

PaO2 - normal to slightly diminished
PaCO2 - normal to slightly diminished
TLC - increased
DLCO - diminished

Question 9

What are the lung function test features of a ‘blue boater’?

Answer 9

PaO2 - low
PaCO2 - elevated
Normal TLC and DLCO

Question 10

What pathologic changes occur with smoking?

Answer 10

Upper lobe centrilobular emphysema

Question 11

What is the pathologic change that occurs with alpha-1 antitrypsin disease?

Answer 11

Panacinar emphysema that favours the lower lobes

Question 12

Which bacterial pathogens can cause community-acquired pneumonia in adults? (5)

Answer 12

Strep pneumonia - most common

Mycoplasma pneumoniae

Chlamydophila pneumoniae

Legionella

HiB - less than 5%

Question 13

How is pneumonia investigated?

Answer 13

CXR - usually establishes diagnosis
O2 saturation - (+/- ABG if severely ill)

Sputum Gram stain and culture appropriate if deep cough + collect specimen before commencing treatment

Question 14

How is mild community-acquired pneumonia treated?

Answer 14

Outpatient

Amox 1g 8 hourly for 5 to 7 days

OR if mycoplasma, chlamydia or legionella suspected

Doxy 200mg for first dose then 100mg daily for further 3 days

Question 15

What is the CORB tool?

Answer 15

Assesses severity of pneumonia based on most abnormal results obtained during initial 24 hours of inpatient stay

C = acute confusion
O = oxygen saturation 90% or less
R = resp rate 30 breaths or more per minute
B = SBP less than 90 or DBP 60 or less

Severe = the presence of at least 2 of these features

Question 16

How do you treat moderate community-acquired pneumonia (nontropical regions)?

Answer 16

Nontropical regions - benpen IV + either oral doxy OR oral clarithro

Question 17

How do you treat moderate community-acquired pneumonia (tropical regions with risk factors)?

Answer 17

Risk factors - diabetes, heavy alcohol consumption, chronic renal failure and chronic lung disease

ceftriaxone IV + gentamicin

Question 18

How do you treat severe community acquired pneumonia? (non tropical)

Answer 18

IV

azithromycin + ceftriaxone or benpen + gent or cefatoxime

Question 19

How do you treat mild hospital-acquired pneumonia (in low risk of MDR organisms scenario)?

Answer 19

amox + clavulanate

OR if nil orally ben pen + gentamicin

Question 20

How do you treat moderate/severe hospital-acquired pneumonia (in low risk of MDR organisms scenario)?

Answer 20

ceftriaxone

Question 21

What Gram stain findings are associated with pneumococcal pneumonia?

Answer 21

Gram positive oval shaped diplococci

Question 22

What Gram stain findings are associaed with S. aureus?

Answer 22

Gram-positive cocci in clusters, chains and pairs

Question 23

What Gram stain findings are associated with N. meningitidis

Answer 23

Gram-negative cocci

Question 24

What Gram stain findings are associated with H. influenzae pneumoniae?

Answer 24

Gram-negative coccobacilli and many PMNs

Question 25

What are the most common causes of typical pneumonia?

Answer 25

S. pneumoniae H. influenzae M. Catarrhalis

Question 26

What are the most common causes of atypical pneumonia?

Answer 26

M. pneumoniae C. pneumoniae Legionella Viruses - influenza, parainfluenza and adenovirus

Question 27

What is the daily regimen for drug-susceptible tuberculosis?

Answer 27

Rifampicin - 6 months Isoniazid - 6 months Pyrazinamide - 2 months Ethambutol - 2 months

Question 28

What are the typical symptoms of active TB?

Answer 28

Night sweats, fever, weight loss and cough, developing over 2-3 weeks or more

Question 29

How is suspected active TB investigated? (3)

Answer 29

1. CXR 2. Sputum cultures x3 3. Acid-fast microscopy using Ziehl-Neelsen stain

Question 30

What is the Mantoux test?

Answer 30

Aka tuberculin skin test Assesses inflammation in dermis following intradermal injection of tuberculin protein. Test needs to be read 48-72 hours after administration.

Question 31

When can false positive Mantoux tests occur?

Answer 31

Previous BCG vaccination and exposure to environmental Mycobacterium spp.

Question 32

Obstructive lung disease - spirometry results

Answer 32

FEV reduced more than FVC therefore, FEV/FVC ratio is decreased

Question 33

Restrictive lung disease - spirometry results

Answer 33

FEV/FVC ratio is normal or increased

Question 34

In which type of COPD patient should supplemental oxygen be given with care?

Answer 34

Blue bloaters - respiratory centres are insensitive to CO2, rely on hypoxic drive to maintain respiratory effort

Question 35

What is Type 1 respiratory failure?

Answer 35

Hypoxia with normal or low PaCO2. Caused by V/Q mismatch - pneumonia, pulmonary oedema, PE, asthma

Question 36

What is type 2 respiratory failure?

Answer 36

Hypoxia with hypercapnia (PaCO2 > 6 kPa). Caused by alveolar hypoventilation, with or without V/Q mismatch - reduced respiratory drive, neuromuscular disease (diaphragmatic paralysis, poliomyelitis), thoracic wall disease (flail chest, kyphoscoliosis), pulmonary disease (asthman, COPD, pneumonia, OSA)

Question 37

How is respiratory failure managed?

Answer 37

Type 1 - treat underlying cause, give oxygen Type 2 - treat underlying cause, be more careful about giving oxygen

Question 38

What is the most common cause of interstitial lung disease?

Answer 38

Idiopathic pulmonary fibrosis

Question 39

Which condition(s) are early inspiratory crackles suggestive of?

Answer 39

COPD/bronchiectasis - often cleared by cough

Question 40

Which condition(s) are late inspiratory crackles suggestive of?

Answer 40

Pulmonary fibrosis

Question 41

What constitutes mild, moderate and severe COPD?

Answer 41

FEV/FVC for all 0.7 (post-bronchodilator) Mild - FEV = 60-80% predicted Moderate - FEV = 40-59% predicted Severe - FEV less than 40% predicted

Question 42

What non-pharmacological interventions should be considered in COPD management? (5)

Answer 42

1. Risk reduction: smoking cessation, influenza and pneumococcal immunisation handbook 2. Optimise function: encourage physical activity, review nutrition, provide education 3. Consider co-morbidities: osteoporosis, coronary disease, anxiety and depression 4. Refer to pulmonary rehab (once moderate severity) 5. Once severe: Consider oxygen therapy, surgery, palliative care and advanced care directive

Question 43

What pharmacological interventions should be considered in the management of COPD? (3)

Answer 43

1. Short-acting reliever medication: e.g. ventolin 2. In moderate severity: Symptom relief e.g. long-acting muscarinic antagonist or long-acting beta agonist 3. Exacerbation prevention: when FEV below 50% predicted AND patient has had 2 or more exacerbations in the previous 12 months - ICS/LABA ccombination therapy e.g. seretide (fluticasone and salmeterol) or symbicort (budesonide and eformeterol)

Question 44

What is Seretide?

Answer 44

Combination therapy - ICS/LABA Fluticasone and salmeterol

Question 45

What is symbicort?

Answer 45

Combination - ICS/LABA Budesonide and eformeterol

Question 46

How does one interpret and increase vs a decrease in tactile fremitus?

Answer 46

Increase = there is a direct solid communication from the bronchus through the lung out to the chest wall e.g. consolidation Decrease = a process is preventing communication e.g. bronchial obstruction or lung is displaced from chest wall by air or fluid in the pleural space

Question 47

What are the classical ECG changes for PE?

Answer 47

"S1Q3T3" 1. S wave in lead 1 2. Q wave and T wave inversion in lead III 3. T wave inversion in leads V1 to V4

Question 48

What causes clubbing?

Answer 48

``` Cyanotic heart disease Lung disease (Abscess, Bronchiectasis, Cystic fibrosis, DON"T SAY COPD, Empyema, Fibrosis) UC/Crohn's disease Biliary cirrhosis Birth defect (harmless) Infective endocarditis Neoplasm (esp. Hodgkins) GI malabsorption (e.g. Coeliac) ```