Respiratory 3

Question 1

What are the key respiratory related symptoms?

Answer 1

Dyspnoea, Cough, Wheeze, Pleuritic Chest Pain, Sputum Production, Haemoptysis, Systemic Symptoms (Fever, Weight Loss, Fatigue)

Question 2

The 4 common presenting symptoms associated with a Deep Vein Thrombosis (DVT)

Answer 2

Leg (commonly calf) pain, Swelling, Warm to touch, Erythema

Question 3

Common presenting symptoms of a Pulmonary Embolism (PE)

Answer 3

Pleuritic Chest Pain, Sudden Onset SOB, Cough +/- Haemoptysis, Dizziness/Syncope, Tachycardia

Question 4

What are the three elements of Virchows Triad?

Answer 4

Vessel Wall Injury, Stasis of Blood Flow (Immobility), Hypercoagulability

Question 5

What is the Well’s Score?

Answer 5

Criteria scoring system when suspecting a Pulmonary Embolism or a DVT. Score 4 or more = PE Likely. Score 2 or more = DVT likely

Question 6

What (7) elements does the Well’s PE Score consist of?

Answer 6

(1) Clinical Signs of a DVT (3 points)
(2) PE #1 diagnosis, alternative diagnosis unlikely (3 points)
(3) Tachycardia (1.5 points)
(4) Immobilisation of 3 days/surgery in previous 4 weeks (1.5 points)
(5) History of DVT or PE (1.5 points)
(6) Haemoptysis (1 point)
(7) Malignancy (treatment <6 months ago or palliative) (1 point)

Question 7

What is the CURB-65 score?

Answer 7

CAP severity score used in predicting mortality and assessing the need for hospital admission.

Question 8

What is the MOA of Unfractionated Heparin?

Answer 8

Found naturally in the body, activates Antithrombin III which inhibits Factor Xa and Thrombin. Giving more enhances this effect.

Question 9

How is Unfractionated Heparin administered?

Answer 9

IV Infusion or S/C Injection

Question 10

Apart from Haemorrhage, what are the two other side effects of Unfractionated Heparin/LMWH?

Answer 10

Hyperkalemia

Thrombocytopenia

Question 11

What is the name of the blood test used to monitor Unfractionated Heparin?

Answer 11

Activated Partial Thromboplastin Time (aPTT)

Question 12

What is the MOA of Low Molecular Weight Heparin (LMWH)?

Answer 12

Similar mode of action to unfractionated heparin but preferentially inhibits factor Xa.

Question 13

What are the main advantages of using Low Molecular Weight Heparin (LMWH) instead of Unfractionated Heparin (UFH)?

Answer 13

Low Molecular Weight Heparin (LMWH) has a more predictable response and greater duration of action - this means that it is administered less frequently (OD or BD) and does not require monitoring.

Question 14

What is the MOA of Warfarin?

Answer 14

Vitamin K Antagonist. Inhibits vitamin K epoxide reductase (enzyme), thereby preventing activation of Vit K and synthesis of factors.

Question 15

What is the normal INR value and what INR target would be expected in a patient who is taking Warfarin?

Answer 15

Normal INR = 1. Target for Warfarin pts = 2-3

Unless PE/DVT at this target, then 3-4

Question 16

Name some of the main disadvantages of using Warfarin

Answer 16

Many food and drug interactions

Teratogenic

Low therapeutic index and unpredictable, hence requiring INR blood test monitoring

Takes 48-72 hours to work

Question 17

What is the MOA of NOACs and DOACs? What are the drug names?

Answer 17

DOAC = Dabigatran, which is a direct thrombin inhibitor.

NOACs = Rivaroxaban, Apixaban, Edoxaban, which directly inhibit factor Xa.

Question 18

In the event of the treatment of a PE/DVT, how long can the patient expect to be taking anticoagulants?

Answer 18

Minimum of 3 months

Question 19

When treating a DVT/PE what (4) main practical considerations should you consider?

Answer 19

1. Hemodynamically unstable or stable?
2. Body weight
3. Active Cancer?
4. Renal function

Question 20

A patient has a confirmed PE/DVT, they have a blood pressure of 90/50. What interventions should be done or considered?

Answer 20

Continuous IV infusion of Unfractionated Heparin, consider thrombolytic intervention.

Question 21

What is the most common LMWH name?

Answer 21

Enoxaparin (Clexane)

Question 22

A patient has a confirmed PE/DVT. They are hemodynamically stable and have no comorbidities. What is the first line medication should they be given?

Answer 22

Apixaban or Rivaroxaban (NOACs)

Question 23

A patient has a confirmed PE/DVT. They have severe renal impairment (CrCl <15ml/min). What is the first line medications should they be given?

Answer 23

LMWH/UFH + Warfarin for at least 5 days until INR 2 on two consecutive readings, then Warfarin alone.

Question 24

A patient has a confirmed PE/DVT. They have active cancer. What medication should they be given?

Answer 24

Dibigatran (DOAC). If not appropriate, LMWH + Warfarin for at least 5 days until INR 2 on two consecutive readings, then Warfarin alone.

Question 25

A patient has a confirmed PE/DVT. They have Antiphospholipid syndrome. What medication should they be given?

Answer 25

LMWH + Warfarin for at least 5 days until INR 2 on two consecutive readings, then Warfarin alone.

Question 26

What does the CURB-65 score comprise?

Answer 26

``` C - Confusion U - Urea >7 mmol/L R - Respiratory Rate > 30 B - Blood Pressure (<90 systolic or <60 diastolic) Over 65 ```

Question 27

An 85 year old man develops shortness of breath and sharp pleuritic chest pain. He recently underwent surgery for a dynamic hip screw, however, he has had poor mobility post-op. He has had 2 episodes of haemoptysis since the onset of symptoms. What is the most likely diagnosis?

Answer 27

Pulmonary Embolism

Question 28

The name of another anticoagulant medication that is chemically related to LMWH, and is an indirect inhibitor of factor Xa, but it does not inhibit thrombin at all.

Answer 28

Fondaparinux

Question 29

Define: Primary/Spontaneous Pneumothorax

Answer 29

Abnormal collection of air within the pleural space. Occurs without cause. Usually occurs in the absence of significant lung disease.

Question 30

Define: Tension pneumothorax

Answer 30

Abnormal/Large collection of air within the pleural space. Occurs when a large amount of air is present within the lung causing the lung to deflate. One way air entry, air can collect on each inspiration, but cannot escape.

Question 31

Define: Traumatic pneumothorax

Answer 31

Abnormal collection of air within the pleural space. Occurs as a result of trauma, e.g. knife wound, blunt trauma

Question 32

What is the most common bacteria associated in community acquired pneumonia (CAP) in an otherwise healthy individual who is over 60 with consolidation changes on chest x-ray?

Answer 32

Streptococcus Pneumoniae still remains the common cause of CAP in over 60s.

Question 33

What (3) atypical bacteria can be responsible for community acquired pneumonia (CAP)

Answer 33

Mycoplasma pneumoniae, Haemophilus influenzae, Legionella pneumophila

Question 34

What are the 3 main viruses causing viral pneumonia?

Answer 34

Influenza A, B, C, Respiratory syncytial virus (RSV), SARS-CoV-2 (COVID-19)

Question 35

In treating a pneumothorax, what is the criteria for conservative management/no treatment?

Answer 35

If no SOB and < 2cm rim of air on the chest x-ray then | no treatment required.

Question 36

In treating a pneumothorax, what is the criteria for treating with needle aspiration?

Answer 36

If SOB and/or > 2cm rim of air on the chest x-ray = aspiration.

Question 37

In treating a pneumothorax, how is needle aspiration performed?

Answer 37

Wide bore cannula, 2nd intercostal space, midclavicular line to decompress/aspirate.

Question 38

In treating a pneumothorax, in what (3) circumstances/pathologies require a chest drain?

Answer 38

Unstable patients, bilateral or secondary pneumothoraces require a chest drain.

Question 39

What are the two main classes of lung cancer? Which type is the most common.

Answer 39

Small cell lung cancer (SMLC) and Non small cell lung cancer (NSCLC). NSCLC are the most common, accounting for 85% of cases.

Question 40

What are some of the risk factors for developing lung cancer?

Answer 40

Smoking, PMH or family history, occupational exposure (asbestos, silica), existing lung disease, radiation of non-lung cancer treatment