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1

What is a defining feature of asthma?

Expiration wheeze
Reversible air flow limitation - usually with a bronchodilator

2

What are the possible classifications of an asthma diagnosis?

1. Possible
2. Probable
3. Definite

3

What immune profile suggests atopy?

Th2

4

Which immune profile strengthens the case for the hygiene hypothesis?

Th1 vs Th2

5

Which immune cells are seen in asthma?

Eosinophils
CD4+ T lymphocytes
Mast cells
Neutrophils (especially in severe asthma)

6

Which immune cells are particularly seen in severe asthma?

Neutrophils

7

What histological features are seen in asthma?

Thickened basement membrane
New vessel formation
Epithelial disruption
Mucus gland hypertrophy

8

Which conditions can result in airflow obstruction?

COPD
Bronchiectstasis
Inhaled foreign body
Obliterative bronchiolitis
Large airway stenosis
Lung cancer
Sarcoidosis

9

How can airflow obstruction be tested for?

Reversibility testing

10

Which test is no use if there is no suspected airflow obstruction?

Reversibility testing

11

What is the differential diagnosis in the event of no airflow obstruction?

Cough syndromes
Hyperventilation
Vocal cord dysfunction
Rhinitis
GORD
Cardiac failure
Pulmonary fibrosis

12

Which white blood cell is commonly raised in asthma?

Eosinophils

13

Which drugs may stimulate an asthma attack?

Beta blockers
Aspirin in 2-3 percent of asthmatics

14

What is the identifying feature in bronchiectasis?

Chronic productive cough

15

How is bronchiectasis diagnosed?

High resolution CT

16

What is the most common cause of cough with no obvious cough?

Acid reflux

17

What feature of a cough indicates acid reflux?

Cough is excessive relative to other asthma symptoms

18

Is acid reflux cough always with dyspepsia?

No

19

In what percentage of asthmatics is aspirin an irritant?

2-3%

20

What clinical features are associated with aspirin induced asthma?

Nasal polyps
Troublesome asthma

21

What features are commonly seen on the FBC of someone with an exacerbation of asthma?

Raised eosinophils and neutrophils

22

What test may be done to investigate the specific trigger of a patients asthma?

Specific IgE finger prick testing

23

What is the airway responsiveness test?

Metacholine challenge
Indirect challenge

24

What are the methods for primary prevention of asthma?

Breastfeeding
Avoid tobacco smoking
?immunotherapy

25

Is it worth avoiding pathogens for primary asthma prevention?

No

26

What are the risk factors for near fatal asthma?

Brittle asthma
Heavy use of beta 2 agonists?
3+ asthma medications

27

How is acute asthma classified?

Near fatal
Life threatening
Acute severe
Moderate
Brittle

28

Which patients can be discharged within 1hr?

PEF>75% after 1hr unless risk factors or living alone

29

What are the features of a moderate asthma exacerbation?

Increasing symptoms
PEF>50-75% best or predicted
No features of acute severe asthma

30

What are the features of acute severe asthma?

PEF 33-50%
RR greater than or equal to 25/min
HR greater than or equal to 110 bpm
Cannot complete sentences in one breath

31

What are the features of life threatening asthma?

Any one of:
PEF

32

What are the clinical features of life threatening asthma?
Normal PCO2
Silent chest
Cyanosis
Feeble respiratory effort
Bradycardi


Normal PCO2
Silent chest
Cyanosis
Feeble respiratory effort
Bradycardia

33

Describe type 1 brittle asthma?

Wide PEF variability (>40% diurnal variation for more than half of the time over 150 days)

34

Describe type 2 brittle asthma

Sudden severe attacks on a background of otherwise well controlled asthma

35

What is near fatal asthma?

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

36

What is the principle of near fatal asthma management?

Bronchodilators to keep the patient alive/ steroids decrease inflammation

37

Which bronchodilators should be used in near fatal asthma?

Salbutamol or tetrabutaline nebs via spacer
Ipratropium if concerned
iv magnesium

38

Which bronchodilator should be used if life threatening asthma becomes near fatal?

Iv aminophylline

39

For how longs should steroids be given in acute exacerbations of asthma?

5 days

40

What steroids can be given in severe asthma?

Prednisolone 40 or 50 od OR
Hydrocortisone 100 or 200mg qds

41

How is acute asthma attack managed?

ABC
O2 - aim for SaO2 >92%
iv fluids for rehydration and to correct electrolytes

42

How does FEV1 and FVC change in obstructive disease?

FEV1 and FVC reduced so FEV1/FVC reduced

43

How does FEV1 and FVC change in restrictive disease?

Both FEV1 and FVC reduced but FEV1 not reduced as much so FEV1/FVC normal or raised

44

What is tidal volume?

Air expired or inspired in a single breath

45

What is inspiratory reserve volume?

Additional volume of air that can be inspired after tidal volume

46

What is expiratory reserve volume?

Additional volume that can be expired after tidal volume

47

What is the vital capacity?

Maximum volume of air that can be exhaled following max inspiration (IRV+TV+IRV)

48

How can lung volume be measured?

Helium method
Body plethysmography

49

How is gas transfer measured?

CO single breath technique

50

How does the helium method work?

Helium acts as a tracer that mixes with air

51

What environmental factors are linked to lung cancer?

Pollution
Coal and tar oils
Chromium
Iron oxide
Asbestos
Radiation
Arsenic

52

Which oncogenes may be present in lung cancer?

KRAS, MYC family, EGFR and ALK mutations

53

Which tumour suppressor genes are relevant to lung cancer?

p53

54

Where can autocrine growth factors be derived from?

Nicotine

55

What percentage of lung cancers are small cell (oat cell) tumours?

10%

56

What types of non small cell lung cancers are there and what is their incidence?

Squamous cell carcinoma (20-30%)
Adenocarcinoma (40-50%)
Large cell carcinoma (10-15%)

57

What are distinctive features of SCLC?

May respond to chemo
Endocrine
Often nodal spread
Early aggression - often inoperable

58

What are features of squamous cell tumours?

Typically in smokers
Often cavitates
High serum calcium due to PTH-rp

59

What are the features of large cell lung cancer?

Early metastasis
Undifferentiated

60

The clinical picture of adenocarcinoma in situ may resemble which other disease?

Pneumonia

61

Which paraneoplastic syndromes are linked to SCLC?

Cushings
Lambert-Eaton syndrome
Limbic encephalitis
Cerebellar syndrome
Dermatomyositis (more common is SCLC)

62

Which paraneoplastic syndrome may be present in squamous cell carcinoma?

Hypercalcaemia due to PTH-rp

63

When should an urgent respiratory referral be made?

CT/CXR suggests cancer including pleural effusion or slow removal of consolidation
High suspicion with normal CT/CXR
Persistent haemoptysis in smokers/ex-smokers older than 40 years of age OR signs of SVCO obstruction or strider

64

Why should an MRI be done?

To look for pan coast tumours

65

What is the ideal pathway in the diagnosis of lung cancer?

Patient presents to GP or A&E
CXR abnormal
Refer to respiratory
Respiratory physician requests CT
CT given with report to team
PET scan
Bronchoscopy/ CT biopsy/ EBUS
Histology and PET report
Decide on chemo/ radio/ surgery

66

What are the symptoms of pleuritic disease?

Asymptomatic
Dry cough
Breathlessness
Pleuritic chest pain
Shoulder pain and heaviness

67

What is an exudate fluid?

More that 30g/l protein in the fluid

68

What is a transudate fluid?

Less that 30g/l protein in the fluid

69

When should Light's criteria be used to differentiate between transudate and exudate?

If the fluid is between 25g/l and 35g/l

70

What is Light's criteria?

The fluid is an exudate if:
Pleural fluid/serum protein > 0.5
Pleural fluid LDH/ serum LDH > 0.6
Pleural fluid LDH > 2/3 of upper limit of serum LDH

71

What can lead to an exudate fluid?

Parapneumonic effusion
Malignancy
PE
Rheumatoid arthritis
Mesothelioma

72

What conditions can lead to a transudate fluid?

Left ventricular failure
Cirrhotic liver disease
Peritoneal dialysis
Nephrotic syndrome
Constrictive pericarditis
Hypothyroidism
Meig's syndrome

73

What is a pleural infection?

Parapneumonic effusion/empyema

74

How should pleural effusion be investigated? (After CXR)

Diagnostic pleural tap

75

What other investigations should be done after a pleural tap when investigating pleural effusion?

Blood culture
USS
CT chest

76

What is the most cause of community acquired pleural infection?

Streptococcus

77

What is the second most common cause of community acquired pleural infection?

Anaerobes

78

What is the third most common cause of community acquired pleural infection?

Staph aureus

79

What is the most common cause of hospital acquired pleural infection?

Staph - MRSA (25%) and S.aureus (10%)

80

How should a pleural infection be managed?

First line- antibiotics
Seconds line- chest tube drainage
Third line- intrapleural fibrinolytics (not routinely used)
Nutritional support
If still doesn't resolve refer to surgeons for VATS/thoracotomy and decortication/open thoracic drainage

81

What is a mesothelioma?

Malignant tumour of the serosal surfaces

82

What is the average latency period of mesothelioma?

40 years

83

What is the prognosis after mesothelioma diagnosis?

Poor 9-12 months

84

What causes a mesothelioma?

Asbestos exposure

85

What signs and symptoms are seen in mesothelioma?

Dull ache in chest
Pleural effusion
Weight loss and fatigue
Chest wall invasion

86

What are the first line investigations in suspected mesothelioma?

CXR and CT thorax

87

What further investigations may be done when investigating mesothelioma?

Pleural fluid analysis (cytology and colour)
Biopsy
Histological subtyping

88

What histological subtypes may be seen in mesothelioma?

Epitheloid - 50% - better prognosis
Mixed (biphasic)
Sarcomatoid

89

Which histological subtype of mesothelioma is the most common and results in the best prognosis?

Epithelial

90

How can pleural effusions be managed?

Drainage (pleurodesis if recurrent)

91

What is the role of radiotherapy in mesothelioma management?

Reduce chest wall invasion risk?

92

Which chemotherapy agents should be used in mesothelioma?

Cisplatin + pemetrexed/ gemcitibine

93

What CXR findings may one see in mesothelioma?

Pleural plaques
Basal thickening

94

What is bronchiectasis?

Permanent dilation of the bronchi and bronchioles with necrosis of their walls

95

What causes bronchiectasis?

Obstruction or childhood viral pneumonia

96

What is a key clinical finding in bronchiectasis?

Foul smelling pus

97

How is bronchiectasis diagnosed?

High resolution CT scan

98

Why does foul smelling pus occur in bronchiectasis?

Air ways become sac like and fill with pus

99

What are the characteristics of the fluid in pulmonary oedema?

Pink and granular with haemosiderin-laden macrophages (heart failure cells)

100

What process occurs in long standing pulmonary oedema?

Resolution or 'brown induration'

101

What causes ARDS?

Diffuse alveolar damage and build up of oedema due to injury to alveolar capillary endothelium

102

What does histology show in ARDS?

Oedema and fluid
Fibrinous membranes lining alveoli
Proceeds to severe scarring

103

Why is ARDS life threatening?

Rapidly developing respiratory insufficiency

104

Which type of PE is immediately life threatening?

Large saddle emboli - lodges are in the bifurcation of the pulmonary trunk

105

What shape of infarct appears in the lungs in the event of a normal PE?

Wedge shaped

106

Does pulmonary circulation normally have a high or low resistance?

Low

107

What can cause pulmonary hypertension?

COPD
Left heart valvular disease
Recurrent thromboemboli

108

What complication arises from pulmonary hypertension?

Right ventricular hypertrophy - chronic cor pulmonale

109

Which type of lung disease does occupational lung disease normally cause?

Restrictive

110

What are the features of coal workers pneumocosis?

Anthracosis
Macules
Progressive massive fibrosis

111

In what jobs is silicon exposure common?

Sandblasting
Foundry work

112

Which disease are due to silicon?

Silicosis
Caplan's syndrome

113

Which conditions are linked to asbestos exposure?

Asbestosis
Pleural plaques
Caplan's syndrome
Mesothelioma
Lung, stomach and colon cancer

114

Which lung disease are due to organic dusts?

Farmer's lung
Baggassosis
Byssinosis
Bird breeder's lung

115

Which habit typically causes chronic bronchitis and emphysema?

Smoking

116

What is centriacinar emphysema?

Central and proximal parts of the respiratory bronchioles affected and the distal parts are spared
This type is seen in smokers

117

What is paracinar emphysema?

Uniform dilation of acini from respiratory bronchiole to alveoli
Seen in alpha 1 anti trypsin deficiency

118

Which type of emphysema is seen in alpha 1 anti trypsin deficiency?

Paracinar

119

What is paraseptal emphysema?

Peripheral along large margins
Occurs adjacent to scarring/collapse/fibrosis
Predisposition to spontaneous pneumothorax in young adults

120

Which type of emphysema predisposes young adults to pneumothorax?

Paraseptal

121

What is irregular emphysema?

Irregular involvement of acini - linked to scarring

122

What is the pathogenesis of emphysema?

Protease-antiprotease hypothesis

Smoking and congenital alpha 1 anti trypsin deficiency leads to antielastase

Smoking and emphysema leads to elastic damage

123

Compare chronic bronchitis to emphysema?

Chronic bronchitis:
Productive cough for longer than 3m in 2 consecutive years
Mucous gland hypertrophy and hypersecretion +/- infection
Progressive
Hypoxia, hypercapnia and cyanosis prone
Blue bloater

Emphysema:
Permanent dilation of airways distal to terminal bronchiole
Elastic destruction leading to loss of elastic recoil
Centriacinar/paracinar/paraseptal/irregular
Tendency to hyperventilate but ABG normal
Pink puffer

124

What is the pathogenesis of lung cancer?

1. Normal respiratory epithelium (pseudo stratified columnar, ciliated, mucous secreting)
2. Turns to stratified squamous
3. Turns to squamous dysplasia
4. Becomes carcinoma

125

What causes hypercapnia?

Hypoventilation

126

What can cause type 1 respiratory failure?

Low inspired oxygen
V/Q mismatch - reduced Q e.g PE
Diffusion abnormality e.g pulmonary fibrosis or emphysema in COPD

127

What can cause type 2 respiratory failure?

Thoracic cage problems e.g. obesity, thoracoplasty and kyphoscoliosis
Hyperexpanded lungs e.g. COPD
Obstructive airway disease e.g. COPD or asthma
Weakness of respiratory muscles e.g. MND, DMD

128

What is CPAP?

Continuous positive airway pressure that pushes air into lungs during expiration
It can expand collapsed portions of lung that are underventilated

129

What improvements are seen with CPAP?

Improves V/Q mismatch
Hypoxia
Keeps airway open in sleep apnoea

130

What is not improved with CPAP?

Hypoventilation

131

Why should too much O2 not be given in type 2 respiratory failure?

It will worsen hypoventilation so will worsen hypercapnia

132

How should oxygen be given in type 2 respiratory failure?

0.5 to 2.0l via nasal cannula with or 24 to 28% with Venturi mask

133

What is the target saturation in respiratory failure?

88 to 92 percent

134

What is non-invasive ventilation?

Improves hypoventilation
Delivers high pressure during inspiration to improve ventilation
Improves hypoxia
Reduces hypercapnia
Useful in hypoventilation and type 2 respiratory failure

135

What are the consequences of type 2 respiratory failure?

Poor sleep
Fatigue
Neuro/psychiatric
Secondary polycythaemia leading to stroke
Pulmonary hypertension
Peripheral oedema
Cor pulmonale

136

What are the complications of chronic hypoxia?

Cor pulmonale
Polycythaemia

137

How should acute type 1 respiratory failure be managed?

High flow oxygen
60 to 100 percent oxygen via mask
Keep sats above 95 percent
Treat underlying cause

138

When should CPAP be considered in type 1 respiratory failure?

Continuing hypoxia

139

How is sleep apnoea diagnosed?

Home sleep study

140

What is the definition of obstructive sleep apnoea?

Repetitive episodes of partial or complete upper airway obstruction during sleep

141

What is apnoea?

Complete stop in airflow for 10s

142

What is hypopnoea?

Reduction in airflow by 50 percent or by 30 percent for at least 10s with desaturation of at least 4 percent

143

What is the AHI? (Same as Sleep Disturbance Index)

Number of apnoeas or hypopnoeas per hour of the study

144

What are the classifications of the AHI?

0 to 5 is normal
5 to 15 is mild
15 to 30 is moderate
30 plus is severe

145

What BMI is linked to OSA?

Greater than 30

146

What are the relevant risk factors for OSA?

Obesity - narrows the upper airway
Micrognathia
Afrocarribean
Neck circumference > 16.5
Tonsillar hypertrophy
Male - longer pharyngeal airway
Acromegaly
Down's syndrome

147

Which system conditions are linked to OSA.

Hypothyroid
Cushing's syndrome
Type 2 DM
Hypertension

148

Which scale is associated with OSA?

Epworth sleepiness scale

149

Which features in the history are suggestive of OSA?

Snoring
Arousals
Waking unrefreshed
Daytime tiredness
Planned or unplanned naps
Witnessed by partner

150

When should CPAP be used?

Moderate or severe OSA

151

When should mandibular splints be advised?

Mile to moderate sleep apnoea
Simple snorers
Intolerance to CPAP

152

What is the aetiology of sarcoidosis?

Exaggerated immune response
Kveim antigen - mycobacterial catalase peroxidase (Kat G)

153

Which gene is linked to acute sarcoidosis lasting less than 2 years with a better prognosis?

DR3

154

Which genes are linked to chronic sarcoidosis?

DR14
DR15

155

Which gene is associated with a better response to anti TNF in sarcoidosis?

TNF variant

156

Which IL variants may occur in sarcoidosis?

IL 12 and IL 23

157

Which other genes are linked to sarcoidosis?

ATNXA11 and XAF1

158

What is the main age range for sarcoidosis?

25 to 45 years

159

Is SACE raised in sarcoidosis?

Yes

160

Is tuberculin raised in sarcoidosis?

No

161

Which CXR features are typically seen in sarcoidosis?

Bilateral hilar lymphadenopathy
Apical involvement

162

What are the clinical features of sarcoidosis?

80 percent of cases are asymptomatic
Dry cough
Breathlessness
Red eyes
Skin lesions
Thirst and polyuria (due to high calcium)
Arthritis
Neurological

163

How should asymptomatic sarcoidosis be monitored?

Monitor lung function and SACE

164

How should symptomatic sarcoidosis be managed?

Steroids

165

How is TB diagnosed?

Sputum smear

166

What antibiotics are given in TB?

Rifampicin
Isoniazid

167

Why does pyrazinamide need to be given with isoniazid?

To prevent antibiotic induced peripheral neuropathy

168

What percentage of TB strains are resistant to isoniazid and rifampicin?

3.5 percent

169

Which immune cells are linked to post-primary TB?

CD4 and CD8

170

What is the mechanism of isoniazid?

Bacteriacidal acting on the cell wall

171

How does rifampicin work?

Bacteriostatic on cell wall

172

How does pyrazinamide work?

Bacteriostatic of FAS11

173

How does ethambutol work?

Bacteriostatic on cell wall

174

What is the second line investigation in someone presenting with TB symptoms?

Mantoux test if under 35
CXR if over 35

175

What type of granuloma is seen in TB?

Caseating granuloma

176

What type of granuloma is present in sarcoidosis?

Non caseating granuloma

177

What is the pathophysiology of primary pneumothorax?

Air leaks from subpleural blebs and Bullard

178

Which are bullae?

Air filled blisters in the visceral pleura

179

What conditions can lead to secondary pneumothorax?

COPD- 60 percent
Asthma
Connective tissue disease e.g. Marfans
Lung fibrosis
TB
CF

180

What are the clinical features of pneumothorax?

Acute pleuritic chest pain +\- shortness of breath
Reduced chest expansion
Hyperresonance
Subcutaneous emphysema - bubble and crack
Quiet breath sounds
Tachycardia

181

How is a small pneumothorax defined?

Less than 2cm on CXR

182

How is large pneumothorax defined?

More than or equal to 2cm on CXR

183

How should a small pneumothorax be managed?

Conservatively with high flow oxygen and let it reabsorb (happens at a rate of 1.25%)

184

When should a pneumothorax be medically managed?

If the rim is greater than 2cm with or without breathlessness

185

How should a large pneumothorax be medically managed?

Aspirated with 16-18G cannula up to 2.5l of air this is considered successful if the rim is now less than 2cm and breathing has improved. If the aspiration is not successful a chest drain can be done (the patient should be admitted).

186

How should a chest drain be managed?

Underwater seal and drainage
Do not lift above waist to prevent retrograde flow of fluid or air
Do not clamp if bubbling or a tension pneumothorax will develop

187

What are the clinical signs of a tension pneumothorax?

Trachea and mediastinum deviate away
Raised JVP
Hypotension
Very breathless

188

How should a tension pneumothorax be managed?

Needle decompression with a large bore (14G) needle in the mid clavicular line 2nd intercostal space

189

What is a PE?

Thrombi from a distant site

190

What percentage of post operative deaths are due to PE?

15%

191

What is the most common cause of maternal death?

PE

192

What percentage of thrombi are formed in the deep veins of the lower limb and pelvis?

75 percent

193

In which veins do thrombi develop?

Deep veins of the lower limb and pelvis

194

What is the pathophysiology of PE?

Thrombi formed in the deep veins of the pelvis and lower limb
Platelet aggregation around venous valve sinuses
Clotting cascade activated

195

What is Virchow's triad?

Injury to vessel wall
Venous stasis
Increased coagulability

196

What can cause PE?

Acute illness
Immobility
Air travel
Trauma
Pregnancy
Oestrogen
Malignancy
Hereditary/acquired thrombophilia

197

How is a PE diagnosed?

CTPA

198

What test should be done in the event of a chronic PE?

V/Q scan (lower radiation)

199

What should be done prior to PE management?

Wells Score

200

What are the components to the Wells score?

Clinical DVT (3 points)
PE most likely diagnosis (3 points)
HR over 100 (1.5 points)
Immobilisation for 3 days or surgery in the last 4 weeks (1.5 points)
Previous DVT/PE (1.5 points)
Haemoptysis (1 point)
Malignancy with treatment in the last 6m (1 point)

201

How should a wells score be graded?

Score over 4 - consider imaging
Score under 4 - rule out PE with a normal D-dimer

202

What findings may show on an ECG with PE?

Sinus tachycardia
RBBB
RV strain (anterior T wave inversion)
S1 Q3 T3

203

What is the medical management of PE?

Anticoagulation with LMWH or warfarin
Thrombolysis

204

What is the interventional radiology management for PE?

Inferior vena cava filter

205

What is the surgical management if PE?

Embolectomy (if life threatening)
Pulmonary thromboendarterectomy (chronic PE)

206

What are the presenting features of a large PE?

Hypotension, collapse and cardiac arrest
Acute right heart strain
Right heart failure

207

What are the features of acute right heart strain?

Loud P2
Splitting of 2nd heart sounds
Gallop rhythm

208

What are the features of right heart failure?

Raised JVP
Low BP
Low cardiac output

209

What are the presenting signs of a PE?

Normal
Sinus tachycardia
New onset AF
Reduced chest movement due to pain
Pleural rub
Pleural effusion
DVT
SOB
Low grade fever
Collapse

210

What are the presenting symptoms of COPD?

Exertional breathlessness
Chronic cough
Regular sputum production and frequent chest infections
Frequent winter bronchitis
Wheeze

211

How is COPD diagnosed?

Post bronchodilator spirometry- not much change in FEV1

212

What are the stages of COPD?

Stage 1 - mild - 80 percent with symptoms
Stage 2 - moderate - 50-79 percent
Stage 3 - severe - 30-49 percent
Stage 4 - very severe - below 30 percent ( or less than 50 percent with respiratory failure)

213

Why is it necessary to do a CXR when diagnosing COPD?

To rule out other causes

214

What further investigations should be done in COPD? After CXR

ABG for respiratory failure and acidosis
FBC to look for anaemia or polycythaemia
BMI calculation

215

Which genetic factor may cause COPD or emphysema in younger patients?

Alpha 1 anti trypsin deficiency

216

What is the first line management in COPD?

Lifestyle changes
Reduction in risk factors such as the pneumococcal and influenza vaccine
Chest physiotherapy if needed
Short acting antimuscarinic (Ipratropium) or beta 2 agonist (salbutamol) PRN

217

Which bacteria is most likely to cause an acute exacerbation of COPD?

H. Influenzae

218

How should mild to moderate COPD be managed?

Inhaled long acting muscarinic (tiotropium) or beta 2 agonist

219

How should severe COPD be managed?

Combination long acting beta 2 agonist and corticosteroids (budesonide + formoterol) or tiotropium

220

If severe COPD remains symptomatic, what is the second line treatment?

Tiotropium + inhaled steroid + long acting beta 2 agonist
(Consider steroid trial, home nebs and theophylline)

221

How can pulmonary hypertension in COPD be managed?

Assess the need for long term oxygen therapy
Treat oedema with diuretics

222

What theoretically can cause asthma?

Air pollution
Allergen exposure
Maternal smoking
Dietary changes
Hygiene hypothesis
Genetics - there is an inheritable component

223

Which non-pharmacological treatments have been proven effective in asthma?

Weight control
Avoid smoking
Buteyko

224

What is the first step in asthma treatment (mild intermittent asthma)?

Short acting beta agonist PRN e.g. salbutamol, terbutaline

225

What is the second step in asthma management (regular preventer therapy)?

Inhaled steroid 200-800 mcg but 400mcg is a good starting dose e.g. beclamethasone, budenoside, fluticasone

226

What is the third step in asthma management? (Initial add on therapy)

Add LABA e.g. Salmeterol or formoterol
if there is not a full benefit from LABA increase inhaled steroid dose to 800mcg
If no response to LABA increase inhaled steroids to 800mcg and try leukotriene antagonist or SR theophylline

227

What is the fourth step in asthma management? (Persistent poor control)

Consider trials of increasing inhaled steroids to 2000mcg
Add fourth drug e.g. Leukotriene receptor agonist, SR theophylline, beta 2 agonist tablets

228

What is step 5 in the management of asthma?

Daily steroid tablets
Consider ways to minimise steroid use
Refer to respiratory

229

What has shown to decrease asthma mortality?

Increased corticosteroid use

230

Give an example of a leukotriene receptor antagonist

Monteleukast

231

What is the mechanism of action of theophylline?

Phosphodiesterase inhibitor

232

What are the indications for anti-IgE therapy?

On maximum inhaled therapy
Impaired lung function
Symptomatic
Frequent exacerbations especially due to allergy
Raise IgE but less than 700iu/litre

233

How does Anti IgE therapy work?

Monoclonal antibody that decreases free IgE

234

Give an example of anti IgE therapy

Omalizumab

235

How is anti IgE therapy given?

2-4 weekly subcutaneous injections

236

What is upper airways disease?

Asthma +\- sinusitis or rhinitis (often coexist)

237

What factors can precipitate asthma?

Viral infection
Dust/ house mites
Animal dander
Pollen
Smoke/ pollution
Exercise
Atmospheric conditions

238

Which lung diseases show a restrictive pattern?

Pleural
Alveolar
Interstitial
Neuromuscular
Thoracic cage

239

What is the vital capacity?

Maximum volume of air that can be exhaled following a maximal inspiration (VC = IRV + TV + ERV)

240

What is the inspiratory capacity?

Volume of air that it is possible to inspire at the end of a normal quiet expiration? (IC = TV + IRV)

241

What is the residual volume?

Volume of air remaining in the lungs and airways at the end of a maximal expiration?

242

What is the functional residual capacity?

Volume of air contained in the lungs at the end of a quiet tidal volume expiration (FRC = RV + ERV)

243

What is the total lung capacity?

The volume of air contained in the lungs at the end of a maximal inspiration (TLC = RV+ERV+TV+IRV)

244

What is Lambert Eaton syndrome? (Can be paraneoplastic in SCLC)

Myaesthenic autoimmune disease where the immune system attacks the neuromuscular junction

245

In TNM staging what is a T1a tumour?

Small peripheral tumour which can be removed surgically

246

What grade is given to a large invading tumour?

T4

247

What is an N1 tumour?

Hilar lymph node involvement

248

What is an N2 tumour?

Mediastinal lymph node involvement

249

What is an N3 grade cancer?

Contractural lymph node involvement

250

What is a grade M1a lung cancer?

Metastatic pleural effusion

251

What is a grade m1b tumour?

Mets at common sides such as liver, lungs, adrenals, brain, bones

252

What are the complications of radiotherapy?

Early-radiation pneumonitis
Late-fibrosis

253

Why may palliative radiotherapy given in lung cancer?

To relieve pain and to stop haemoptysis and neurological problems through brain and spinal mets

254

What is the survival advantage when giving chemo in lung cancer?

Small

255

Which chemotherapy agents are given in small cell lung cancer?

Pemetrexed and cisplatin

256

What other agents may be combined with chemo in lung cancer?

EGFR antagonists such as endotinib

257

What palliative treatments can be given in lung cancer?

Endobronchial laser to relieve obstruction, breathlessness and haemoptysis
Stenting to relieve breathlessness
Endobronchial radiotherapy (brachytherapy)

258

Why type of fluid do disease affecting local factors in the lung produce?

Exudate

259

What type of fluid do diseases affecting systemic factors produce?

Transudate

260

Which diseases affect local factors in the lung and what conditions do they produce?

Increased capillary permeability - trauma, malignancy, inflammation, infection, pancreatitis
Increased pleural permeability - inflammation, malignancy and PE
Decreased lymphatic drainage - malignancy and trauma
Increased negative pleural pressure - atelectasis, mesothelioma

261

Which systemic factors affecting the lung are affected by which disease?

Increased capillary hydrostatic pressure - heart failure
Increased pulmonary interstitial fluid - heart failure
Decreased intravascular oncotic pressure - hypoalbuminaemia, cirrhosis
Increased flow from other cavities - peritoneal dialysis, liver cirrhosis

262

What is the progression of a pleural infection?

Simple parapneumonic effusion to complicated parapneumonic effusion to empyema

263

What are the characteristics of the fluid produced in simple parapneumonic effusion?

Clear, sterile fluid with normal pH, glucose and LDH that resolves with LDH
Chest drain not usually required

264

What are the characteristics of the fluid produced in a complicated parapneumonic effusion?

Fibrinopurulent stage, fluid infected but not purulent. pH 1000iu/l, gram stain may be positive
Chest drain needed

265

What is the characteristic of the fluid in empyema?

Pus in the pleural space, free flowing or multiloculated, fluid gram stain may be positive. Fibroblasts may have cause a thickened pleura.
Drainage required

266

What is the incidence of pneumonia?

5 - 11 cases per 1000 adults

267

What is the 30 day mortality of pneumonia?

18.3 percent

268

What are symptoms of pneumonia?

Cough
Pleural pain
Dyspneoea
Tachypnoea
Sweating, fevers, shivers, aches, pain, fevers

269

What are the signs of pneumonia?

New and focal chest signs
Radio graphic changes - new radio graphic shadowing with no other explanation

270

Do most cases of pneumonia have an unidentified pathogen?

Yes

271

What is the most common pathogen in pneumonia?

Strep pneumoniae

272

When should healthcare associated pneumonia be considered?

Inpatient longer than 48hrs or 10 days post discharge or living in nursing home

273

Which pathogens are common in HAP?

H. Influenza, Gram negative bacilli, S.aureus all increased due to aspiration

274

Which pathogens are less likely in HAP?

Legionella and unknown pathogens

275

Which pathogens are more common in the elderly?

M. pneumonia and legionella

276

How does alcohol influence pneumonia?

Increased risk of most pathogens
Aspiration most likely

277

How does diabetes influence pneumonia?

Increased risk of bacteraemic pneumococcal pneumonia

278

What impact does COPD have on pneumonia?

H.influenza and M.catarrhalis more likely
Increased symptoms but same mortality

279

Which bacteria is almost unseen in HAP?

Legionella

280

Which can disrupt filtration and increase deposition in the upper airways?

Anatomical abnormalities

281

What can affect the cough reflex leading to increased chance of aspiration?

Neurological conditions e.g. stroke

282

What can reduce mucocilliary clearance?

Cystic fibrosis
Bronchiectasis

283

What can damage and reduce alveolar macrophages?

Alcoholism

284

What reduces humoral and cellular immunity?

HIV

285

What can negatively affect the oxidative metabolism of neutrophils?

Chemotherapy

286

What are the components of the CURB65 score?

Confusion AMTS less than 8
Urea equal to or greater than 7mmol/l
Respiratory rate greater than 30
BP systolic less than 90/ diastolic less than or equal to 60
65 - age 65 plus

287

How does the CURB65 score influence pneumonia treatment?

0-1 treat at home - amoxicillin 500mg tds oral
2 short admission - amoxicillin 500mg tds oral
3 plus admit - urgent senior review amoxicillin 500mg tds oral + clarithromycin 500mg bd oral
4-5 admit into ITU/HDU - coamoxiclav 1.2g tds IV and clarithromycin 500mg bds IV
If legionella expected give levofloxacin

288

What does the trachea consist of?

C shaped cartilage
Mucinous glands

289

What do the bronchi consist of?

Discontinuous cartilage plates and mutinous glands

290

What do the bronchioles consist of?

No cartilage or mucous glands
Terminal bronchioles are less than 2mm in diameter
Gas exchange occurs in the terminal bronchioles

291

What do the alveolar ducts consist of?

Flat epithelium, no glands or cilia

292

What do the alveolar sacs consist of?

No glands or cilia

293

What does Eisenmeger syndrome consist of?

Right to left shunt via VSD
Hypertrophic right ventricle
Patent ductus arteriosus

294

What are the defence mechanisms of the lung?

Particles bigger than 10 microns held in the upper airway
3-10 microns held in tracheobronchial mucus (mucocilliary action)

295

Which age group does lobar pneumonia typically affect?

Previously healthy males aged 20-50

296

What is the pathophysiology of lobar pneumonia?

Congestion (24hrs) - vessels engorged, oedema in alveoli, heavy red lung
Red hepatisation (2-4d) - outpouring of neutrophils and RBCs into alveoli, red, solid, airless liver like lung
Grey hepatisation (4-8d) - fibrin and macrophages replace neutrophils and RBCs. Grey, solid and airless lung.
Resolution (8-10d) - gradual return to normal

297

What is a serious complication of lobar pneumonia?

Lung abscess or empyema especially with Klebsiella or Staph aureus

298

What is the most common type of pneumonia?

bronchopneumonia

299

What are the 4 typical clinical settings where bronchopneumonia occurs?

Chronic debilitating illness
Old age
Infancy
Secondary to viral infection

300

What is the pathophysiology of bronchopneumonia?

Bilateral, basal and patchy progressing to grey/red spots of consolidation and microscopically acute inflammatory infiltrate in bronchioles and alveoli

301

What CXR findings are present in bronchopneumonia?

Focal opacities, clinical signs are less pronounced, usually patchy bilateral basal distribution.

302

Which pathogens are typically responsible in bronchopneumonia?

Staph, strep viridians, pneumococcus, haemophilia, pseudomonas, coliforms

303

What is atypical pneumonia?

Interstitial pneumonia

304

What are the clinical signs of interstitial pneumonia?

Patchy or extensive
Congested and subcrepitant lungs
Secondary bacterial infection
More generalised symptoms rather than local
Usually sporadic
Usually mild and self limiting
Possible DAD (diffuse alveolar damage)

305

What are predisposing conditions to interstitial pneumonia?

Malnutrition, alcoholism, debilitating illness

306

What is the pathogenesis of interstitial pneumonia?

Intra alveolar proteinaceous material forming hyaline membranes in the case of DAD

307

What is found on histology with interstitial pneumonia?

Inflammation restricted to alveolar septa and interstitial pneumonia
No/minimal alveolar exudate

308

What pathogens may be present in interstitial pneumonia?

Mycoplasma pneumoniae
Viruses: influenza A and B, RSV, adenovirus, rhinovirus, rubeola, varicella
Chlamidya
Coxiella
Often undetermined

309

Which pathogens cause TB?

M.tuberculosis
M.bovis

310

What is the pathogenesis of TB?

Cell mediated hypersensitivity central to development of characteristic destruction through caseating necrosis and cavitation
Macrophages phagocytose but cannot kill bacteria so they multiply, lyse and infect other cells
T cell mediated immunity 2-3 weeks post infection:
CD4 mediated IFN gamma secretion intracellular killing and granuloma formation
CD8 mediated lysis of macrophages and killing
CD4-/CD8- mediated lysis of macrophages and caseation and necrosis; bacilli killed in an anoxic, acidic environment

311

What is primary TB?

Represents first reponse to tubercle bacili
Usually asymptomatic

312

What is the pathophysiology of primary TB?

Ghon complex (typically 1cm focus in midzone with draining lymph node) that leads to fibrosis and calcification

313

What is the pathophysiology of secondary TB?

Reinfection or reactivation, sometimes progressive primary TB
Bacteria relocate to high oxygen areas of the lung
Usually apical granuloma 3cm at presentation

314

Which type of hypersensitivity is relevant to primary TB?

Type IV (delayed type)

315

What can be seen on histology with TB?

Granulomas with caseous necrosis
Langhans giant cells
Epitheloid macrophages

316

What does a Ziehl-Neelsen stain reveal with TB?

Characteristic acid-fast bacilli

317

What are the complications of pulmonary TB?

Progressive fibrocavitary TB - gradually destroys lung through necrosis, cavitation and fibrosis
Miliary TB - blood bourne dissemination within lung or throughout the body, seed like foci consisting of granulomas in meninges, bone marrow, liver or any other organ

318

Which patients get fungal pneumonia?

Immunocompromised

319

Which fungi is responsible for fungal pneumonia in HIV patients?

Pneumocystis carinii (PCP)

320

What is the human response to primary TB?

No pre existing immunity
Non infectious
High mortality
Often outside lung
Children and elderly
HIV co infection

321

What is the human response to post primary TB?

Pre existing immunity
Infectious
Cavities with TB biofilm
Surprisingly well tolerated
Young adults effected
Immunocompetent with CD4 and CD8 involvement

322

What are the side effects if isoniazid?

Liver damage - raised ALT
Peripheral neuropathy
Nausea
Tiredness

323

What are the side effects of rifampicin?

Liver damage - raised bilirubin
Flu like syndrome
Low platelets

324

What are side effects of pyrazinamide?

Flushing
Arthritis
Liver damage

325

What are the side effects of ethambutol?

Optic neuritis