Respiratory

Question 1

Causes of severe pulmonary oedema

Answer 1

CV: usually LVF (post-MI or IHD), valvular heart disease, arrhythmias, malignant HTN
ARDS from any cause: trauma, malaria, drugs, sepsis
Fluid overload (iatrogenic)
Neurogenic (e.g. head injury)

Question 2

Ix for pulmonary oedema

Answer 2

CXR: ABCDE
ECG: signs of MI or dysrhythmias
UEC: troponin, ABG
Consider echo
Plasma BNP may be helpful if Dx is in question (high negative predictive value)

Question 3

Mx of pulmonary oedema (should be commenced before Ix)

Answer 3

Monitoring progress: BP, pulse, cyanosis, RR, JVP, urine output, ABGs
Once stable and improving: daily weights (aim for reduction of 0.5kg/day), QDS obs, repeat CXR, manage underlying cause

Question 4

6 causes of pneumothorax

Answer 4

Spontaneous (esp in young thing men) due to rupture of subpleural bulla
Chronic lung disease (e.g. asthma, COPD, CF, lung fibrosis, srcoidosis)
Infection (e.g. TB, pneumonia, lung abscess)
Traumatic, including iatrogenic (e.g. CVP line insertion, pleural aspiration or biopsy, percutaneous liver biopsy, positive pressure ventilation)
Carcinoma
Connective tissue disorders

Question 5

Signs of pneumothorax

Answer 5

Reduced chest expansion
Hyper-resonance to percussion and diminished breath sounds on affected sounds
If tension pneumothorax: deviation of trachea, respiratory distress, tachycardia, hypotension, distended neck veins

Question 6

Ix for pneumothorax

Answer 6

IF SUSPECT TENSION PNEUMOTHORAX, IMMEDIATE PLEUROCENTESIS IS INDICATED (do not delay for CXR; can do CXR later)
Expiratory plain film: look for area devoid of lung markings (ensure suspected pneumothorax is not a large emphysemous bulla)
ABG

Question 7

Mx of pneumothorax

Answer 7

Pleurocentesis
Chest drain (ICC) if secondary to trauma or mechanical ventilation, or if aspiration unsuccessful in a significant, symptomatic pneumothorax
Seek surgical advice if bilateral pneumothoraces, lung fails to expand after ICC insertion, recurrent pneumothoraces or Hx of pneumothorax on OPPOSITE side
FU: CXR after 24hrs and 7-10 days to exclude recurrence, avoid air travel for 6/52, avoid diving permanently

Question 8

Tension pneumothorax

Answer 8

Air drawn into pleural space with each inspiration has no route of escape during expiration; mediastinum is pushed over into contralateral hemithorax, kinking and compressing the great veins
Unless air is rapidly removed, cardiac arrest will occur

Question 9

Mx of tension pneumothorax

Answer 9

Pleurocentesis: large-bore (14-16G) needle with syringe, partially filled with 0.9% saline (acts as water seal), into 2nd intercostal space in midclavicular line (or 4-6th in midaxillary) on side of suspected pneumothorax

Question 10

Insertion of chest draina

Answer 10

Site: 4-6th intercostal space, anterior- to mid-axillary line
Removal: consider when drain is no longer bubbling and CXR shows re-inflation

Question 11

RFs for PE

Answer 11

Malignancy
Surgery (esp pelvic and lower limb; risk greatly reduced by DVT prophylaxis)
Immobility
Combined OCP (slight risk with HRT)
Previous thromboembolism and inherited thrombophilia

Question 12

CXR findings in PE

Answer 12

Often normal

May be decreased vascular markings,small pleural effusion, wedge-shaped area of infarction, atelectasis

Question 13

Ix for PE

Answer 13

ABG: hypoxia, respiratory alkalosis
D-dimer: high sensitivity but low specificity (increased if thrombosis, inflammation, post-op, infection, malignancy), good to EXCLUDE PE
CTPA: sensitive and specific
V/Q: if CTPA unavailable or contraindicated

Question 14

Mx of PE

Answer 14

O2 if hypoxic (10-15L/min)
Morphine
If critically ill with massive PE, consider immediate thrombolysis with alteplase
Otherwise: LMWH and warfarin until INR >2, compression stockings for prevention of further PE
FU: 6/52 warfarin if obvious remedial cause (otherwise consider >3-6/12 or long term if recurrent or underlying malignancy), Mx of underlying cause

Question 15

When is an IVC filter indicated?

Answer 15

When patients cannot be anticoagulated, or in case of recurrent VTE in patients who are optimally anticoagulated

Question 16

Dx of TB

Answer 16

Latent: Mantoux, followed by Quantiferon Gold (measure IFN-y response to MTB) if positive
Active respiratory: sputum samples (>3, one early morning, before commencing treatment; try bronchoscopy and lavage if cannot obtain sample) with MCS for acid-fast bacilli on ZN staining
Active non-respiratory: try to get samples (sputum, pleura and pleural fluid, urine, pus, ascites, peritoneum, bone marrow, CSF) for MCS
PCR for rapid identification of MDR-TB
Histology: caseating granuloma
CXR findings: consolidation, cavitation, fibrosis, calcification

Question 17

Mx of TB

Answer 17

2/12 of RIPE initially:
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
4/12 of RI to continue

Question 18

SEs of rifampicin

Answer 18

Increased LFTs (esp bilirubin)
Thrombocytopaenia
Orange discolouration of urine, tears and contact lens
Flu Sx

Question 19

SEs of isoniazid

Answer 19

Increased LFTs
Decreased WCC
Neuropathy (if this occurs, stop and give pyridoxine)

Question 20

SEs of ethambutol

Answer 20

Optic neuritis (colour vision is first to deteriorate; test before commencing treatment and throughout FU)

Question 21

SEs of pyrazinamide

Answer 21

Hepatitis
Arthralgia
CI in gout and porphyria

Question 22

Clinical features of TB

Answer 22

Pulmonary: cough, sputum, malaise, night sweats, haemoptysis
Miliary (following haematogenous dissemination): non-specific or overwhelming signs, consider lung, liver, LN or marrow biopsy
Genitourinary: LUTS, haematuria, sterile pyuria
Bone: vertebral collapse, Pot’s vertebra
Skin (lupus vulgaris): jelly-like nodules
Peritoneal: abdominal pain, GI upset
Acute TB pericarditis
Chronic pericardial effusion and constrictive pericarditis
TB meningitis: very poor prognosis

Question 23

Chemoprophylaxis for asymptomatic TB infection

Answer 23

1-2 anti-TB drugs for shorter periods (e.g. rifampicin and isoniazid for 3/12, or isoniazid alone for 6/12)

Question 24

Malignant mesothelioma

Answer 24

Tumour of mesothelial cells that usually occurs in the pleura (rarely in peritoneum or other organs)
Associated with occupational exposure to asbestosis (latent period between exposure and deveopment of tumour may be up to 45 years)

Question 25

Sx of mesothelioma

Answer 25

``` Chest pain Dyspnoea Weight loss Finger clubbing Recurrent pleural effusions ```

Question 26

Ix for mesothelioma

Answer 26

CXR: pleural thickening/effusion, may be pleural plaques if previous asbestosis

Question 27

Dx of mesothelioma

Answer 27

On histology, usually following a thoracoscopy

Question 28

Mx of mesothelioma

Answer 28

Chemotherapy: pemetrexed + cisplatin Radiotherapy controversial Pleurodesis and indwelling pleural drain may help Sx

Question 29

Prognosis of mesothelioma

Answer 29

Poor (without pemetrexed,

Question 30

Sarcoidosis

Answer 30

Multisystem granulomatous disorder of unknown cause | Usually affects adults aged 20-40

Question 31

Causes of bilateral hilar lymphadenopathy

Answer 31

Sarcoidosis Infection (e.g. TB, mycoplasma) Malignancy (e.g. lymphoma, carcinoma, mediastinal tumours) Pneumoconioses, i.e. organic dust disease (e.g. silicosis, berylliosis) Extrinsic allergic alveolitis Histocytosis X

Question 32

Clinical features of sarcoidosis

Answer 32

``` Often asymptomatic (detected on CXR) Acute: erythema nodosum, polyarthralgia Pulmonary disease: dry cough, progressive exertional dyspnoea, chest pain Non-pulmonary: lymphadenopathy, hepatosplenomegaly, uveitis, conjunctivitis, glaucoma, subcutaneous nodules, cardiomyopathy, arrhythmias, hypercalcaemia, neurosarcoidosis ```

Question 33

Ix for sarcoidosis

Answer 33

Increased ESR Decreased WCC Increased LFTs Increased immunoglobulins Increased Ca2+ (also calcuria) Lung function: may be normal or show restrictive defect Tissue biopsy is diagnostic: shows non-caseating granuloma

Question 34

Mx of sarcoidosis

Answer 34

With BHL alone: no need for treatment, most recover spontaneously Acute: steroids Indications for steroids: parenchymal lung disease, uveitis, hypercalcaemia, neurological or cardiac involvement (high dose pred for 4-6/52 then decrease over 1 year) Anti-TNFa or lung transplant in refractory cases

Question 35

Prognosis of sarcoidosis

Answer 35

60% with thoracic sarcoidosis recover over 2 years 20% respond to steroid therapy In rest, improvement is unlikely despite therapy

Question 36

DDx of granulomatous disease

Answer 36

Infections: bacterial (e.g. TB, leprosy, syphilis), fungal (e.g. cryptococcus) AI: PBC Vasculitis: GCA, polyarteritis nodosa, Takayasu's arteritis, Wegener's granulomatosis Pneumoconioses: silicosis, berylliosis Idiopathic: Crohn's disease, de Quervain's thyroiditis, sarcoidosis Extrinsic allergic alveolitis Histiocytosis X

Question 37

Causes of transudate pleural effusion

Answer 37

Increased venous pressure: HF, constrictive pericarditis, fluid overload Decreased oncotic pressure: cirrhosis, nephrotic syndrome, malabsorption Hypothyroidism

Question 38

Causes of exudate pleural effusion

Answer 38

Infection: pneumonia, TB Inflammation: pulmonary infarction, RA, SLE Malignancy: bronchogenic carcinoma, malignant metastases, lymphoma, mesothelioma, lymphangitis carcinomatosis

Question 39

Sx of pleural effusion

Answer 39

May be asymptomatic Dyspnoea Pleuritic chest pain

Question 40

Signs of pleural effusion

Answer 40

``` Decreased chest expansion Stony dull percussion Diminished breath sounds Decreased vocal resonance and fremitus May be bronchial breathing ABOVE the pleural effusion due to compression of the lung Tracheal deviation if large effusion ```

Question 41

Ix of pleural effusion

Answer 41

CXR: costophrenic blunting U/S: to identify presence of pleural fluid and guide diagnostic or therapeutic aspiration Diagnostic aspiration: percuss the upper border of the pleural effusion, choose site 1-2 intercostal spaces below it, aspirate 10-30mL fluid through 21G needle and send to lab for clinical chemistry (protein, glucose, pH, LDH, amylase), MCS, cytology and if indicated immunology (e.g. RhF, ANA) Pleural biopsy if analysis is inconclusive

Question 42

Mx of pleural effusion

Answer 42

Drainage if symptomatic (with chest drain if empyema) Pleurodesis with tetracycline, bleomycin or talc if recurrent effusions (talc most useful for malignant effusions) Surgery if persistent collections and increasing pleural thickness

Question 43

Interpretation of cytology of pleural fluid

Answer 43

Neutrophils ++: parapneumonic effusion (i.e. in pneumonia), PE Lymphocytes ++: malignancy, TB, RA, SLE, sarcoidosis Mesothelial cells ++: pulmonary infarction Abnormal mesothelial cells: mesothelioma Multinucleated giant cells: RA

Question 44

Interpretation of clinical chemistry of pleural fluid

Answer 44

Protein under 25g/L: transudate Protein >35g/L: exudate Glucose under 3.3mmol/L, pH under 7.2, raised LDH: empyema, malignancy, TB, RA, SLE Increased amylase: pancreatitis, carcinoma, bacterial pneumonia, oesophageal rupture

Question 45

Lung abscess

Answer 45

Cavitating area of localised, suppurative infection within the lung

Question 46

Causes of lung abscess

Answer 46

Inadequately treated pneumonia Aspiration (e.g. alcoholism, oesophageal obstruction, bulbar palsy) Bronchial obstruction (tumour, foreign body) Pulmonary infarction Septic emboli (septicaemia, right heart endocarditis, IVDU) Subphrenic or hepetic abscess

Question 47

Clinical features of lung abscess

Answer 47

``` Swinging fever Cough productive of purulent, foul-smelling sputum Pleuritic chest pain Haemoptysis Finger clubbing ```

Question 48

Bronchiectasis

Answer 48

Chronic infection of bronchi and bronchioles leading to permanent dilatation of these airways

Question 49

Main organisms in bronchiectasis

Answer 49

Haemophilus influenzae Strep pneumoniae Staph aureus Pseudomonas aeruginosa

Question 50

Signs of bronchiectasis

Answer 50

Finger clubbing | Coarse inspiratory crepitations

Question 51

Cystic fibrosis

Answer 51

AR condition caused by mutations in CFTR gene | Defect in Cl- channel caudes defective chloride secretion and increased Na+ absorption

Question 52

Clinical features of CF

Answer 52

Respiratory: cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale GI: pancreatic insufficiency (DM, steatorrhoea), gallstones, cirrhosis Other: male infertility, OP, arthritis, vasculitis, nasal polyps, sinusitis

Question 53

Signs of CF

Answer 53

Cyanosis Finger clubbing Bilateral coarse crackles

Question 54

Mx of CF

Answer 54

Multidisciplinary involvement is indicated Chest: physio regularly, Abx for acute infective exacerbations or prophylactically, mucolytics, bronchodilators GI: pancreatic enzyme replacement, fat soluble vitamin supplements

Question 55

HPOA

Answer 55

Hypertrophic pulmonary osteoarthropathy (usually associated with lung cancer)

Question 56

Causes of ARDS

Answer 56

Pulmonary: pneumonia, aspiration, inhalation, injury, vasculitis, contusion Trauma: haemorrhage, head injury, shock, burns Septicaemia DIC Pancreatitis Acute liver failure Drugs/toxins: aspirin, heroin, paraquat

Question 57

Clinical features of ARDS

Answer 57

``` Cyanosis Tachypnoea Tachycardia Peripheral vasodilatation Bilateral fine inspiratory crackles ```

Question 58

Ix for ARDS

Answer 58

CXR: bilateral pulmonary infiltrates | PCWP to rule out HF

Question 59

Dx of ARDS

Answer 59

These 4 must exist: 1) Acute onset 2) CXR: bilateral infiltrates 3) PCWP less than 19mmHg or lack of clinical congestive HF 4) Refractory hypoxaemia

Question 60

Mx of ARDS

Answer 60

ICU admit Give supportive therapy and treat underlying cause Respiratory support: CPAP with O2 but most pts will require mechanical ventilation Circulatory support: invasive haemodynamic monitoring with an arterial line and Swan-Ganz catheter (pulmonary artery catheterisation)

Question 61

Prognosis of ARDS

Answer 61

Mortality is 50-75%