Respiratory Flashcards
1
Q
What are the British thoracic society guidelines on what constitutes an acute severe asthma attack?
A
PEF 33-50% best or predicted
Resp rate 25 or above
Heart rate 110 or above
Inability to complete sentences in 1 breath
2
Q
What are the British thoracic society guidelines on what constitutes a moderate asthma attack?
A
Increasing symptoms
PEF >50-75% best or predicted
No features of acute severe asthma
3
Q
What are the British thoracic society guidelines on what constitutes a life threatening asthma attack?
A
PEF <33% best or predicted SpO2 less than 92% PaO2 less than 8kPa Normal PaCO2 (4.6-6 kPa) Silent chest Cyanosis Poor resp effort Arrhythmia Exhaustion, altered conscious level Hypotension
4
Q
What are the British thoracic society guidelines on what constitutes a near fatal asthma attack?
A
Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
5
Q
For someone presenting with an acute severe asthma attack, what drugs should be administered immediately and by what route? If they fail to respond to this, what should you give now?
A
Oxygen Nebulised salbutamol or terbutaline Nebulised ipratromium bromide Oral prednisolone or IV hydrocortisone If fails: IV magnesium sulphate, IV salbutamol, IV aminophylline
6
Q
Why is a normal CO2 result in a patient with an acute severe asthma attack worrying? What further intervention would you do for this patient?
A
Suggests patient is tiring, would expect it to be low if they were adequately compensating
Intubation/ventilation in ITU
7
Q
A 23 year old man is seen in ED with 10% pneumothorax of the right lung. His BP and pulse are stable. What needs to be done?
A
Oxygen therapy only as he is stable
8
Q
What are risk factors for DVT and PE?
A
Thrombophilia - protein s and c Factor VIII excess Factor V Leiden Pregnancy Pre eclampsia Surgery Age over 35 Malignancy Smoking Obesity Immobility Parity above 4
9
Q
What is bilateral hilar lymphadenopathy characteristic of?
A
Sarcoidosis
10
Q
What skin condition is acute sarcoidosis associated with?
A
Erythema nodosum
11
Q
What is amyloidosis?
A
Extra cellular deposits of degradation resistant protein amyloid
12
Q
What are causes of amyloidosis?
A
Primary: no cause is found
Secondary: TB, bronchiectasis, RA, osteomyelitis, neoplasia
13
Q
How is a diagnosis of amyloidosis made?
A
Rectum biopsy
Congo red staining of affected tissue
14
Q
Give examples of transudative causes of pleural effusion
A
Nephrotic syndrome
Liver cirrhosis
Heart failure
15
Q
What are features of COPD on a chest X-ray?
A
Hyperinflation
Flattened hemidiaphragms
Hyperlucent lung fields
16
Q
If there is a white out on chest X-ray and the trachea is pulled towards it, what are differentials?
A
Pneumonectomy
Complete lung collapse
Pulmonary hypoplasia
17
Q
If there is a complete white out on chest X-ray and the trachea is central, what are differentials?
A
Consolidation
Pulmonary oedema
Mesothelioma
18
Q
If there is a complete white out on chest X-ray but the trachea is pushed away, what are differentials?
A
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
19
Q
What common clinical signs are found with a PE?
A
Tachypnoea
Crackles
Tachycardia
Fever
20
Q
What is the Wells score for PE?
A
Clinical signs and symptoms of DVT - leg swelling and pain on palpation (3) Alternative diagnosis less likely (3) Heart rate >100 (1.5) Immobilisation for more than 3 days or surgery in previous 4 weeks (1.5) Previous DVT/PE (1.5) Haemoptysis (1) Malignancy (1) Score more than 4: PE likely
21
Q
What are features of small cell lung cancer?
A
Central
Associated ectopic ADH, ACTH secretion: Hyponatraemia, Cushings
Lambert Eaton syndrome
22
Q
What is management of small cell lung cancer?
A
Usually metastatic at diagnosis
Early stage disease: T1-2a surgery
Limited disease: chemotherapy and adjuvant radiotherapy
Extensive disease: palliative chemo
23
Q
What are the BTS guidelines for management of spontaneous pneumothorax?
A
Primary: if rim of air is <2cm and patient not short of breath, discharge, otherwise attempt aspiration, if this fails then chest drain, advice stop smoking
Secondary: if over 50 and rim of air over 2cm or SOB then chest drain, rim of 1-2cm - aspiration, if this fails then chest drain. All patients admitted for 24h. If less than 1cm rim give oxygen and admit for 24h
24
Q
What are the steps of asthma management in the new BTS guidelines?
A
Initial step: low dose inhaled corticosteroid in combination with a short acting beta agonist
Next step: add long acting beta agonist ideally in combo inhaler
Next step: if no response to LABA, stop and increase ICS to medium. If response to LABA, continue and increase ICS to medium. Alternative try a leukotriene antagonist, SR theophylline or LAMA
Next step: trials of ICS high dose, add fourth drug, refer to specialist care
Next step: regular oral steroids at lowest dose to achieve control
25
What are features of mycoplasma pneumonia?
Prolonged and gradual onset
Flu like symptoms precede dry cough
Bilateral consolidation on X-ray
26
What are some complications of mycoplasma pneumonia?
```
Cold agglutins (IgM) may cause haemolytic anaemia
Erythema multiforme/nodosum
Meningoencephalitis
Guillain-Barré syndrome
Bullous myringitis: vesicles on TM
Pericarditis/myocarditis
Hepatitis
Pancreatitis
Acute glomerulonephritis
```
27
What investigations are done for mycoplasma pneumonia?
Mycoplasma serology
| Positive cold agglutination test
28
What is the management of mycoplasma pneumonia?
Erythromycin/clarithromycin
29
What is given to treat low or moderate severity community acquired pneumonia?
Oral amoxicillin. Add macrolide if admitted
30
What should be given to treat high severity community acquired pneumonia?
IV co amoxiclav and clarithromycin
or cefuroxime and clarithromycin
or cefotaxime and clarithromycin
31
What are some intrathoracic complications of carcinoma of the bronchus?
Pleural effusions
Recurrent laryngeal nerve palsy
SVC obstruction
Horners syndrome
32
What are clinical features of mesothelioma?
Chest pain
Dyspnoea
Blood stained pleural effusion
33
What causes farmers lung?
Hypersensitivity reaction to saccharopolyspora rectivirgula
34
What is the treatment of choice for farmers lung (hypersensitivity pneumonitis)?
Prednisolone
35
What are clinical features of cystic fibrosis?
Persistent productive cough (esp winter)
Haemoptysis
Clubbing
Low pitched inspiratory and expiratory crackles
36
What does chest X-ray of a patient with cystic fibrosis show?
Cystic shadows
Fluid levels
Tramline or ring shadows
37
What is the acute management of asthma?
```
Oxygen
Salbutamol nebs
Steroids IV
CXR rule out pneumothorax
Magnesium 2g over 30 mins
IV theophylline
ITU review if silent chest or tiring patient
```
38
How does idiopathic pulmonary fibrosis typically present?
Male aged 50-70
Progressive exertional dyspnoea
Clubbing
Restrictive picture on spirometry
39
Which virus causes bronchiolitis?
Respiratory syncytial virus
40
Which virus causes croup?
Parainfluenza virus
41
Which virus causes the common cold?
Rhinovirus
42
Which bug is the most common cause of community acquired pneumonia?
Streptococcus pneumoniae
43
Which bug is the most common cause of bronchiectasis exacerbations?
Haemophilus influenzae
44
Which bug causes pneumonia particularly following influenza?
Staphylococcus aureus
45
What is the common cause of pneumonia in HIV patients?
Pneumocystis jiroveci
46
What are general management pieces of advice to give to a patient with COPD?
Smoking cessation advice
Annual influenza vaccination
One off pneumococcal vaccination
47
What is first line treatment for COPD?
SABA or SAMA
48
What is the second step in COPD management?
If FEV1 >50%: LABA or LAMA
| If FEV1 <50%: LABA and ICS in combo inhaler or LAMA
49
What are features of cor pulmonale?
Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud P2
50
How do you treat cor pulmonale?
Loop diuretic for oedema
| Long term oxygen therapy
51
What factors may improve survival in patients with stable COPD?
Smoking cessation
Long term oxygen therapy in those who fit criteria
Lung volume reduction surgery in selected patients
52
What are key indications for non invasive ventilation?
COPD with respiratory acidosis pH 7.25-7.35
Type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation
53
What are some causes of bronchiectasis?
Post infective: TB, measles, pertussis, pneumonia
Cystic fibrosis
Bronchial obstruction: cancer, foreign body
Immune deficiency: selective IgA, hypogammaglobulinaemia
Allergic bronchopulmonary aspergillosis
Ciliary dyskinetic syndrome: kartageners, youngs
Yellow nail syndrome
54
What is a ghon focus?
Lesion seen in lung caused by TB
| Calcified tuberculous caseating granuloma
55
What is miliary TB?
Erosion through a vein that leads to widespread dissemination of mycobacterium tuberculosis to a range of different organs including bones and kidneys
56
In what range of pH is NIV considered of most benefit in patients with COPD?
7.25-7.35
57
How is PCP pneumonia best detected?
Bronchoscopy and bronchial aspirate
58
What is Potts disease?
Tuberculosis infection of the spine
59
What is the clinical picture of aspergillus fumigatus?
```
Wheeze
Cough
Dyspnoea
Recurrent pneumonia
Raised serum IgE
Raised ESR
Raised eosinophil count
```
60
What are contraindications to surgery for lung cancer?
```
SVC obstruction
FEV <1.5L
Malignant pleural effusion
Vocal cord paralysis
Stage IIIb or IV
Tumour near hilum
```
61
What are characteristics of squamous cell cancer of the lung?
Central
PTHrP secretion - hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy
62
What are features of adenocarcinoma of the lung?
Peripheral
| Most common lung cancer in non smokers
63
What are features of large cell lung carcinoma?
Peripheral
Anaplastic, poorly differentiated tumours with poor prognosis
May secrete beta HCG
64
What is Kartageners syndrome?
```
Primary ciliary dyskinesia
Dextrocardia or situs inversus
Bronchiectasis
Recurrent sinusitis
Subfertility
```
65
What are features of a mycoplasma pneumoniae pneumonia?
Prolonged gradual onset
Flu like symptoms precede a dry cough
Bilateral consolidation
66
What are possible complications of mycoplasma pneumoniae?
```
Cold agglutinins (IgM) - haemolytic anaemia, thrombocytopenia
Erythema multiforme, erythema nodosum
Meningoencephalitis
Guillain Barre
Bullous myringitis
Pericarditis/myocarditis
Hepatitis
Pancreatitis
Acute glomerulonephritis
```
67
How is mycoplasma pneumoniae investigated?
Mycoplasma serology
| Positive cold agglutination test
68
How is mycoplasma pneumoniae managed?
Erythromycin /clarithromycin
69
Which patients should be assessed for long term oxygen therapy?
```
Severe airflow obstruction: FEV1 <30% predicted
Cyanosis
Polycythemia
Peripheral oedema
Raised JVP
Oxygen sats less than 92% on air
```
70
How is assessment for long term oxygen therapy made in patients with COPD?
Measuring ABG on 2 occasions at least 3 weeks apart
71
Who should be offered long term oxygen therapy?
```
PO2 <7.3 or if 7.3-8 and:
Secondary polycythemia
Nocturnal hypoxaemia
Peripheral oedema
Pulmonary HTN
```
72
What is the most appropriate next step for a 71 year old patient presenting with a 2 month history of cough and associated weight loss who has a suspicious lung mass on chest X-ray?
Contrast enhanced CT of chest, liver and adrenals
73
In which respiratory condition would a patient present with desaturation on exertion but with a normal chest X-ray and a history of recurrent chest infections?
Pneumocystis jiroveci
74
What is the most common opportunistic infection in AIDS? Who should have prophylaxis?
Pneumocystis jiroveci
| All patients with CD4 count below 200
75
How is pneumocystis jeroveci managed?
Co trimoxazole
IV pentamidine in severe cases
Steroids if hypoxic
76
What are features of idiopathic pulmonary fibrosis?
Progressive exertional dyspnoea
Bibasal crackles on auscultation
Dry cough
Clubbing
77
What investigation is required to make a diagnosis of idiopathic pulmonary fibrosis?
High resolution CT
78
What is the management for idiopathic pulmonary fibrosis?
Pulmonary rehabilitation
Pirfenidone (anti fibrotic agent)
Supplementary oxygen
Lung transplant
79
What is the prognosis for idiopathic pulmonary fibrosis?
3-4 years life expectancy
80
What is the main therapeutic benefit of using inhaled corticosteroids in COPD?
Reduced frequency of exacerbations
81
What is the target INR for a patient with recurrent PEs?
3.5
82
68 year old gentleman presents to GP with dry, persistent cough for anumber of weeks. Wife has noticed is becoming more short of breath when exercising. Reduced exercise since retirement so not noticed any change himself. Current smoker of 10/day for 30 years. Retired labourer/builder
O/E: slight SOB on entering the consultation room, Evidence of digital clubbing. Bilateral inspiratory crackles on auscultation. What are differential diagnoses?
```
Heart failure
COPD
PE
Lung Cancer
Infection
Interstitial lung disease
```
83
What specific questions might you want to ask in a patient who you suspect has interstitial lung disease?
Environmental / occupational exposure: Asbestos, industrial dust, farmer, Pigeon breeding, Contaminated ventilation
PMH of connective tissue disease
Detailed drug history: Abx – nitrofurantoin, Anti-inflammatories – methotrexate, Biological agents, CV agents – amiodarone, Chemotherapeutics
84
What are some physiological and radiological features of interstitial lung disease?
Physiological: Restrictive ventilation defect on lung function tests, Small lung volumes, Reduced gas transfer
Radiological: CXR – small lung volumes with reticulonodular shadowing, HRCT – ground glass changes, honeycomb cysts and traction bronchiectasis
85
What investigations might you want to do for interstitial lung disease?
Bloods:FBC – lymphopenia in sarcoidosis, eosinophilia, neutrophilia inhypersensitivity pneumonitis, ESR, CRP – non specifically elevated, Ca2+ - raised in sarcoidosis
Auto-immune screen – connective tissue disease
Imaging: CXR, HRCT
Special test: Lung function tests – restrictive pattern, Bronchoscopy, Bronchoalveolar lavage – may differentiate diagnosis / exclude infection, Biopsy – useful in sarcoidosis, Surgical biopsy
86
What is idiopathic pulmonary fibrosis?
Progressive fibrosing interstitial pneumonia of unknown origin
Clinical syndrome associated with histological and radiological pattern of Usual Interstitial Pneumonia
Patchy interstitial fibrosis
Architectural alteration – honeycomb changes
Repeated episodes of focal damage to the alveolar epithelium
Diagnosis of exclusion based on history, examination, investigations
87
How is idiopathic pulmonary fibrosis diagnosis?
HRCT with characteristic features has a high positive predictive value
If diagnostic uncertainty = biopsy
Ideally surgical lung biopsy, Transbronchial lung biopsy invariably insufficient at obtaining tissue sample
88
How is idiopathic pulmonary fibrosis managed?
Pirfenidone – recommended by NICE but only with FVC 50-80% predicted (downregulation of production of growth factors and procollagens)
Supportive measures: Exercise, Physio, Vaccinations, Oxygen in hypoxaemia
Lung transplant
89
What is sarcoidosis?
Multisystem granulomatous disorder characterised by presence of non-caseating granulomas
Granulomas consist of focal accumulations of epithelioid cells, macrophages and lymphocytes (mainly T cells)
Commonly affects young adults
Presents with bilateral hilar lymphadenopathy, pulmonary infiltration
and skin/eye lesions
Unknown aetiology
90
What are some extra pulmonary manifestations of sarcoidosis?
Skin lesions: Erythema nodosum
Occular: Anterior uveitis – misting of vision, pain and red eye
Metabolic manifestations: Hypercalcaemia
CNS
Bone and joint involvement: Bone cysts
Hepatosplenomegaly
91
What is the management for sarcoidosis?
Mainstay = corticosteroids if symptomatic
Spontaneous remission occurs in the majority of patients therefore if no organ damage treatment can be held for 6 months
If impairment appears – prednisolone to be started immediately
92
What is the prognosis for sarcoidosis?
More severe in certain groups - Afro-Caribbean ethnicity
Fatal in fewer than 5% in the UK
Remission within 2 years in 2/3rds of pt with bihilar lymphadenopathy alone
Lung function tests useful to monitor progression
93
What is extrinsic allergic alveolitis?
Widespread diffuse inflammatory reaction of small airways and
alveoli due to inhalation of different antigens
Commonly microbial spores of contaminated vegetable matter
Farmer’s lung – mouldy hay
Bird fancier’s lung – handling pigeons, proteins present in the feathers and excreta
Inhalation of antigen leads to allergic response through deposition of immune complexes and development of small non-caseating
granulomas
94
What are features of extrinsic allergic alveolitis?
Fever, malaise, cough and SOB
Develop several hours after exposure to antigen
O/E: Coarse end-inspiratory crackles and wheeze throughout chest
Ventilation-perfusion mismatch causing cyanosis
If continued exposure – chronic illness with severe weight loss andfeatures of idiopathic pulmonary fibrosis
95
What is the management for extrinsic allergic alveolitis?
Prevention: avoidance of trigger
| Induce regression with prednisolone
96
What are some examples of occupational lung disease?
Coal worker’s pneumoconiosis
Asbestosis
Mesothelioma
97
What can coal workers pneumoconiosis develop into?
Simple pneumoconiosis – deposition of coal dust
Progressive massive fibrosis - round fibrotic masses with necrotic central cavities. Mixed restrictive and obstructive ventilation defect
98
Why does asbestos cause significant problems with lungs?
Highly resistant fibres that readily get trapped in the lung – resistant to macrophage and neutrophil enzymatic destruction
99
How might mesothelioma present?
Persistent chest wall pain
| Pleural effusions
100
58 year old man. Presenting with increasing SOB and cough productive of purulent green sputum – increased over the past 3 days. Regular medications including Spiriva 18 micrograms OD, Ventolin MDI 200micrograms PRN, Indapamide 2.5mg OD, Atorvastatin 10mg OD. No known drug allergies. PMH – COPD diagnosed 5 years ago. Current smoker 60 pack year history. On examination: Speaking in partial sentences, RR 29, SpO2 85% on air, widespread expiratory wheeze and inspiratory coarse crackles of left base, hyperinflated chest, using accessory muscles for respiration. HR 116, BP 109/76. Alert, BM normal. Temp 37.9. ABG shows a respiratory acidosis. What is the diagnosis?
Infective exacerbation of COPD
| Type 2 respiratory failure
101
What is the management for an infective exacerbation of COPD?
Controlled oxygen therapy – replacing non-rebreathe if used with venturititrated to maintain O2 sats 88-92%
Nebulisers (Ipratropium/ salbutamol)
Prednisolone
Abx
102
Which COPD patients should be considered for NIV?
All patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 >7.26) persists despite immediate maximum standard medical treatment on controlled oxygen therapy for no more than one hour
103
What are common causes of type 1 respiratory failure?
Pneumonia
PE
Asthma
Pulmonary fibrosis
104
What is the management for PE?
O2 – titrate to maintain sats 94-98%
Enoxaparin treatment dose 1.5mg/kg
CTPA
105
What is the definition of chronic bronchitis?
Sputum production on most days for at least 3 months of the year for at least 2 years
106
What are the 2 tests for TB and when are they used?
Mantoux - purified protein derivative injected intradermally, result read 2-3 days later
Interferon gamma blood test used if mantoux is positive or unequivocal or in people where tuberculin test may be false negative - miliary TB, sarcoidosis, HIV, lymphoma, less than 6 months old
107
What is hypertrophic osteoarthropathy?
Periosteal reaction involving long bones of distal extremities without underlying bone lesion
Clubbing of fingers when associated with a pulmonary condition, it is termed hypertrophic pulmonary osteoarthropathy (HPOA) and when associated with cancer is considered a paraneoplastic syndrome
108
Which type of lung cancer is associated with hypercalcaemia?
Squamous cell carcinoma
| Due to parathyroid hormone related peptide release
109
What is a ghon complex?
Ghon focus: tubercle laden macrophages develops small lung lesion
This combined with hilar lymph nodes is a ghon complex
110
What are the possible sites for secondary tuberculosis?
```
Lungs
CNS: tuberculous meningitis
Vertebral bodies: Potts disease
Cervical lymph nodes: scrofuloderma
Renal
GI tract
```
111
What 2 features define finger clubbing?
Loss of obtuse angle between the nail and dorsum of the finger
Thickening of the nail bed
112
What are the respiratory causes of finger clubbing?
```
Carcinoma of the bronchus
Pulmonary fibrosis
Brochiectasis
Empyema/lung abscess
Asbestosis/mesothelioma
```
113
What is pickwickian syndrome?
Obesity hypoventilation syndrome
Failure to breathe rapidly or deeply enough resulting in low sats and high CO2 levels
Commonly associated with OSA
114
When is latent TB treated in HIV positive patients?
| What is the treatment?
If positive test for latent TB
If contact with sputum positive person
Past history of untreated TB
Isoniazid orally for 9 months
115
What is hypertrophic pulmonary osteoarthropathy?
Clubbing and periostitis of the small hand joints especially the DIPs and MCPs
Distal expansion of long bones and painful swollen joints
Can be primary but also secondary to lung cancer
116
What are extrapulmonary manifestations of mycoplasma pneumonia?
```
Haemolytic anaemia
Renal failure
Hepatitis
Myocarditis
Meningism and meningitis
Transverse myelitis
Cerebellar ataxia
```
117
What are management options for obstructive sleep apnoea?
CPAP
Weight loss
Smoking cessation
118
What is caplans syndrome?
Combination of RA and pneumoconiosis that manifests as intrapulmonary nodules on chest X-ray
119
How is aspergilloma diagnosed?
Presence of serum antibodies against Aspergillus fumigatus
| Mycological examination of sputum
120
What is hyatid disease of the lung? How is it treated?
Caused by echinococcus granulosus
When humans ingest embryo of dog tapeworm
Cause hyatid cysts which can form in liver, lung, kidneys and brain
Treat with albendazole
121
What are the rules on driving HGVs with obstructive sleep apnoea?
Cease driving until stable on therapy - CPAP
| Required to have annual review
122
What is the next step for COPD patients who remain breathless or have exacerbations despite using short acting bronchodilators?
FEV1 >50%: long acting beta agonist or long acting muscarinic antagonist
FEV1 <50%: LABA and ICS or LAMA
123
In which lung cancer patients would a pet scan be useful?
Non small cell cancer to establish eligibility for curative treatment
124
What are indications for non invasive ventilation?
COPD with resp acidosis 7.25-7.35
Type 2 resp failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation
125
What is the most common form of asbestos related lung disease?
Pleural plaques
126
What are features of cystic fibrosis?
```
Bronchiectasis
Infertility
Recurrent pancreatitis
Biliary cirrhosis
Nasal polyps
Pneumothorax
```
127
What condition causes fluffy nodular shadowing, streaky shadows particularly in upper zones on chest X-ray?
Hypersensitivity pneumonitis
128
What are indications for long term oxygen therapy?
```
p02 less than 7.3
Or those with 7.3-8 plus:
Secondary polycythemia
Nocturnal hypoxaemia
Peripheral oedema
Pulmonary HTN
```
129
What signs on examination are suggestive of a PE?
```
Tachycardia
Tachypnoea
Hypotension
Gallop rhythm
Raised JVP
Loud second heart sound in pulmonary area
Right ventricular heave
Pleural rub
Cyanosis
Atrial fibrillation
```
130
What ECG changes can be seen with a PE?
```
Normal
Sinus tachycardia
Right ventricular strain in V1-V3
Right axis deviation
Right bundle branch block
Atrial fibrillation
Deep S waves in I
Q waves in III
Inverted T waves in III
```
131
What is the management algorithm for COPD?
Mild FEV 80% predicted or more: active reduction of risk factors, flu vaccine, SABA
Moderate FEV between 50 and 79% predicted: add regular LABA and rehab
Severe FEV between 30 and 49% predicted: add inhaled glucocorticoids if repeated exacerbations
Very severe FEV less than 30% predicted/resp failure: add long term 02, consider surgery
132
Who should be offered the BCG vaccine?
All infants 0-12 months living in areas of UK where annual incidence of TB is more than 40/100000
All children with parent or grandparent who was born in country with annual incidence over 40/100000 (if 6 or more need tuberculin test first)
Previously unvaccinated tuberculin negative contacts of resp TB cases
Previously unvaccinated tuberculin negative new entrants to UK under 16 who were born in/lived in country with high incidence
Healthcare workers
Prison staff
Staff of care home for elderly
Those who work with homeless people
133
What are contraindications to BCG vaccine?
```
Previous BCG
Past Hx of TB
HIV
Pregnancy
Positive tuberculin test (heaf or mantoux)
```
134
What are common causes of lobar collapse?
Lung cancer
Asthma (mucous plugging)
Foreign body
135
What investigations should be performed for a patient with suspected TB?
```
Chest X-ray
Sputum smear for acid fast bacilli
Sputum culture (3 samples)
Tuberculin skin testing
FBC
Lymph node fine needle aspiration
Pleural fluid analysis by thoracocentesis
HIV test
```
136
What are important management steps for a patient with confirmed active TB?
Notify PHE
Antibiotics: 6 months RI, 2 months with PE
Contact tracing
Direct observed therapy if considered high risk poor adherence
137
What is idiopathic pulmonary artery hypertension? How does it present?
Pulmonary artery pressure >25 at rest, >30 with exercise
Diagnosed when no underlying cause can be found
More common in females
Progressive SOB
Cyanosis
Right ventricular heave, loud P2, raised JVP with prominent a waves, tricuspid regurgitation
138
What is the management of idiopathic pulmonary artery hypertension?
```
Echo
Diuretics if right heart failure
Anticoagulation
Vasodilator therapy: calcium channel blocker, IV prostaglandins, bosentan (endothelin 1 antagonist)
Heart lung transplant
```
139
What is lights criteria for distinguishing between transudate and exudate?
Protein: exudate >30, transudate <30
If between 25-35 use criteria
Exudate likely if: fluid/serum ratio protein >0.5, fluid/serum LDH >0.6, fluid LDH >2/3 upper limit of normal serum
140
Which patients should be assessed for the need for LTOT in COPD?
```
Very severe airway obstruction: FEV1 <30% predicted
Cyanosis
Polycythemia
Peripheral oedema
Raised JVP
Sats 92% or less on air
```
141
Which patients with COPD should be offered LTOT?
PO2 <7.3 on two occasions at least 3 weeks apart
| Or PO2 of 7.3-8 and one of: secondary polycythemia, nocturnal hypoxaemia, peripheral oedema, pulmonary HTN
142
What is the commonest neurological manifestation of sarcoid?
Facial nerve palsy
143
What are predisposing factors for OSA?
Obesity
Macroglossia: acromegaly, hypothyroidism, amyloidosis
Large tonsils
Marfans
144
What is the management of OSA?
Weight loss
CPAP first line for moderate or severe
Intra oral devices (mandibular advancement)
145
What are advantages and disadvantages of metered dose inhalers?
Cheap, quick and convenient to use
Needs good co-ordination
Poor inhaler technique is common
When used correctly only 10%-20% of the drug reaches lungs
146
What are advantages and disadvantages of using a spacer device with an MDI?
Holds drug like reservoir
Removes need for co-ordination of breathing and actuation
Pharyngeal deposition is greatly reduced
Smaller particles penetrate further into lungs depositing agreater proportion of drug
Available with mask
Electrostatic charge reduces delivery
147
What are advantages and disadvantages of breath activated MDIs?
Spring mechanism is triggered by inspiratory flow rate of 22-36 L/m
Drug delivery less dependent on technique
When cap is removed inhaler is primed and ready to fire
Generally bigger than MDIs
148
What are advantages and disadvantages of dry powder inhalers?
Inspiratory airflow releases fine powder (therefore no co-ordination needed)
Inspiratory flow rate needed - may be a problem with some devices
Turbohalers have no taste, hence there could be uncertainty it has been taken by the patient
Turbohalers delivers 20%-30% of drug
Accuhalers deliver 11%-15% of drug
Not suitable for young children
149
What are side effects of steroid inhalers?
Sore throat/hoarse voice
Oral thrush
Higher risk of osteoporosis with long term use of high dose steroids
150
What are benefits of maintenance and reliever therapy as combined inhalers?
Helps to overcome poor adherence with ICS
Can reduce risk of asthma attacks requiring oral steroids in
patients who are not controlled on maintenance ICS alone (with separate relief medication)
Reduces number of inhalers a patient needs
151
What do the BTS guidelines say about use of MART therapy?
For adults over age of 18, combined maintenance and reliever therapy can be considered for patients who have a history of asthma attacks on medium dose ICS or ICS/LABA
152
What are examples of MART inhalers?
Symbicort: budesonide/formoterol 6microg formulations (200/6 or 100/6). 1-2 puffs BD + 8 additional puffs as maintenance (max 12 puffs)
Duoresp: 6microg formulation (200/6). 1-2 puffs BD + 8 additional puffs as maintenance (max 12 puffs)
Fostair: 6microg formulation (100/6). 1-2 puffs BD + 6 additional puffs as maintenance (max 10 puffs)
153
What are indications for steroids in sarcoidosis?
Parenchymal lung disease
Uveitis
Hypercalcaemia
Neurological or cardiac involvement
154
What are complications of lung tumours?
```
Recurrent laryngeal nerve compression
SVCO
Horners
Rib erosions
Pericarditis
AF
Mets: bone, brain, liver, adrenals
Ectopic hormones: SIADH, ACTH
```
155
What are complications of staphylococcal pneumonia?
```
Air cavity (pneumatocele)
Air leaks (pneumothorax, pneumomediastinum, subcuteneous emphysema)
Necrotizing Pneumonia (PVL-Panton-Valentine Leukocidin producing S. aureus)
```
156
What are extrapulmonary manifestations of mycoplasma pneumonia?
```
Ear infection
Cervical lymp nodes
Urticaria
Erythema multiforme
Autoimmune Haemolysis
```
157
What are risk factors for viral pneumonia?
Smoking exposure
Poor socioeconomic status
Pre-existing chronic conditions (CF, CLD, CHD, immunodef)
158
What are viral causes of pneumonia?
```
Influenza A and B
Parainfluenza
RSV
HMV (humanemetapnemovirus)
Adenovirus
Rhinovirus
Varicella
CMV
```
159
What does viral pneumonia look like on a chest X-ray?
Non specific , widespread infiltrate rather than lobar
160
What is ABPA?
Allergic bronchopulmonary aspergillosis
Hypersensitivity response to fungus aspergillus, commonly in patients with asthma or cystic fibrosis
Features: eosinophilia, raised serum IgE, transient pulmonary infiltrate on chest X-ray, microscopically detectable hyphae of A. Fumigatus
161
What is Williams Campbell syndrome?
```
Deficiency of bronchial cartilage
Persistent cough
Wheeze
Impaired lung function
Overinflated lungs
Bronchomalacia
```
162
A 45 year old asthmatic presents with night time wheezing and coughing despite being on regular beclometasone (400 micrograms/day) inhaled steroids, what is the next step?
Long acting beta 2 agonist
163
If a patient struggles with using a metered dose inhaler, what could be offered as alternative?
Breath actuated device: accuhaler, easibreathe, turbohaler
Haleraid (device to place over MDI to aid if impaired strength in hands)
Spacing device
164
Which inhaled drugs are useful for preventing exercise induced bronchospasm?
Leukotriene receptor antagonists
165
What are causes of bilateral hilar lymphadenopathy?
TB
Lymphoma
HIV
Sarcoid
166
What are the antibodies targeted against in goodpastures disease?
Basement membrane collagen
167
How is goodpastures managed?
Immunosuppressants
Plasma exchange
Renal support
168
What are complications of mycoplasma pneumonia?
```
Meningoencephalitis
Polyneuritis
Monoarticular arthritis
SJS
Myocarditis
Hepatitis
DIC
Haemolytic anaemia
```
169
What is hypersensitivity pneumonitis?
Extrinsic allergic alveolitis
Inflammation of alveoli due to hypersensitivity to organic dusts
Usually hobby or occupation induced, symptoms relieved when away from precipitating factor
170
What might be seen on X-ray and pulmonary function tests in extrinsic allergic alveolitis?
Diffuse nodular interstitial pattern with ground glass appearance in lower and middle zones
Reduced diffusion capacity of lungs for carbon monoxide
171
What is the most common site for aspiration pneumonia? What clinical findings might you expect?
Right lower lobe
Bronchial breathing at right base due to consolidation of alveoli allowing superior transmission of sounds through bronchi and bronchioles to periphery of lung
172
What sound might be heard if there is a bronchial tumour in a lung?
Monophonic wheeze - mass partially obstructing airway
173
What lung sounds would be expected in idiopathic pulmonary fibrosis?
Fine inspiratory bibasal crackles
174
What sounds would be expected in a haemothorax?
Stony dullness to percussion
| Absent breath sounds
175
What are the main indications for placing a chest tube in pleural infection?
Patients with frankly purulent or turbid/cloudy pleural fluid on sampling
Presence of organisms identified by Gram stain and/or culture from non purulent pleural fluid sample
Pleural fluid pH <7.2 in patients with suspected pleural infection
176
What should a pleural aspirate be sent for?
```
pH
Protein
LDH
Cytology
Microbiology
```
177
What is lights criteria?
Exudate protein >30
Transudate <30
If protein between 25-35 apply lights criteria. Exudate likely if:
Pleural fluid protein/serum >0.5
Pleural LDH/serum >0.6
Pleural LDH more than 2/3 upper limits of normal serum
178
How should COPD be managed?
```
Smoking cessation advice
Annual flu vaccine
One off pneumococcal vaccine
SABA or SAMA first line
FEV1 >50%: LABA or LAMA
FEV1 <50%: LABA and ICS combo or LAMA
Then if LABA, switch to LABA and ICS
Give LAMA and LABA and ICS combo
Theophylline after trials of long acting or if inhaled therapy not tolerated
Mucolytics if chronic productive cough
```
179
What are the TB drugs and their mechanisms of action?
Rifampicin: inhibits DNA dependent RNA polymerase preventing transcription
Isoniazid: inhibits mycolic acid synthesis
Pyrizinamide: inhibits fatty acid synthase
Ethambutol: inhibits polymerisation of arabinose
180
What are side effects of TB drugs?
Rifampicin: liver inducer, hepatitis, orange secretions, flu like symptoms
Isoniazid: peripheral neuropathy, hepatitis, agranulocytosis, liver inhibitor
Pyrizinamide: hyperuricaemia (gout), arthralgia, myalgia, hepatitis
Ethambutol: optic neuritis
181
What is the latent period of asbestosis from time of exposure?
15-30 years
182
Where is the fibrosis in asbestosis?
Lower lobe fibrosis
183
Which is the most dangerous form of asbestos for causing mesothelioma?
Crocidolite (blue) asbestos
184
What are possible features of mesothelioma?
Progressive shortness of breath
Chest pain
Pleural effusion
185
What is the median survival from diagnosis of mesothelioma?
8-14 months
186
What different pathologies of the lung can be caused by asbestos?
Pleural plaques (benign)
Pleural thickening
Asbestosis
Mesothelioma
187
What is bronchiectasis?
Permanent dilatation of airways secondary to chronic infection or inflammation
188
What is management for bronchiectasis?
Assess for treatable cause (immune deficiency etc)
Physical training (inspiratory muscle training)
Postural drainage
Antibiotics for exacerbations, long term rotating abx in severe cases
Bronchodilators
Immunisations
Surgery
189
What are the most common organisms isolated from patients with bronchiectasis?
Haemophilus influenzae
Pseudomonas aeruginosa
Klebsiella
Strep pneumoniae
190
Which drugs can cause pulmonary fibrosis?
```
Amiodarone
Bleomycin
Methotrexate
Sulfasalazine
Gold
Nitrofurantoin
Bromocriptine
Cabergoline
```
191
What is an essential study before a CTPA in PE?
Chest X-ray
192
What are differences in emphysema findings in alpha 1 antitrypsin deficiency and COPD?
Alpha 1 antitrypsin: lower lobe emphysema
| COPD: upper lobe emphysema
193
What is alpha 1 antitrypsin deficiency?
Inherited condition caused by lack of protease inhibitor normally produced by liver
Panacinar emphysema marked in lower lobes
Liver cirrhosis and hepatocellular carcinoma
Cholestasis in children
194
What is management of alpha 1 antitrypsin deficiency?
No smoking
Supportive: bronchodilators, physiotherapy
IV alpha 1 antitrypsin protein concentrates
Surgery: volume reduction surgery, lung transplant
195
What are the antibiotics of choice for whooping cough?
Less than 1 month old: clarithromycin
Age 1 month or older: azithromycin or clarithromycin
Pregnant women: erythromycin
196
Which causes of fibrosis typically affect lower zones?
Idiopathic pulmonary fibrosis
Connective tissue disorders (except ank spond)
Drug induced: amiodarone, bleomycin, methotrexate
Asbestosis
197
Which causes of fibrosis typically affect the upper zones?
```
Extrinsic allergic alveolitis
Coal workers pneumoconiosis/progressive massive fibrosis
Silicosis
Sarcoidosis
Ank spond
Histiocytosis
TB
```
198
What features of asthma suggest poor control?
```
Having to use salbutamol over 3 times a week
Reduced FEV1
Needing rescue medications
Waking up at night with symptoms
Interfering with life
```
199
What is the definition of COPD?
Chronic bronchitis: cough with sputum for most days for 3 months of 2 years
Emphysema: permanent dilatation with destruction of alveolar walls distal to terminal bronchioles
Less than 15% reversibility of FEV1 with bronchodilators
200
What are criteria for long term oxygen therapy?
Non smoker
PaO2 <7.3 in air
Or less than 8 in air with evidence of pulmonary HTN
201
What are causes of apical fibrosis?
```
EAA
Ank spond
Sarcoidosis
TB
Silicosis
```
202
What are causes of basal pulmonary fibrosis?
Idiopathic pulmonary fibrosis
Connective tissue disease
Asbestosis
Aspiration (recurrent)
203
Which drugs cause pulmonary fibrosis?
Amiodarone
Nitrofurantoin
Sulfasalazine
Methotrexate
204
What are treatments for CF?
```
Postural drainage
Chest physio
Active cycle breathing, flutter device
Creon and fat soluble vitamins
Immunisations
DNase
Antibiotics
```
205
What are causes of bronchiectasis?
Congenital: CF, hypogammaglobulinaemia, primary ciliary dyskinesia, kartageners, youngs
Post infectious: pertussis, ABPA, measles, recurrent aspiration, severe pneumonia, TB
Mechanical: foreign body, tumour
Other: RA, IBD, sjogrens, SLE, yellow nail syndrome
206
What causes pleural effusion?
Transudate: cardiac failure, renal failure, liver failure, hypoalbuminaemia
Exudate: parapneumonic, empyema, malignancy, inflammatory (RA, SLE)
207
What degree of reversibility do you expect to see in asthma on spirometry with bronchodilators?
>15%
208
What are risk factors for obstructive sleep apnoea?
```
Obesity
Acromegaly
Enlarged tonsils/adenoids
Nasal polyps
Alcohol
```
209
What are management options for obstructive sleep apnoea?
```
Weight loss
Avoid alcohol
Sleep upright
Mandibular advancement device
CPAP
Surgery (adenoidectomy)
```
210
What might sleep studies show in a patient with obstructive sleep apnoea?
At least 15 apnoeic episodes per hour of sleep
211
What are risk factors for pneumothorax?
```
Previous pneumothorax
COPD
Chronic lung disease: CF, alpha 1 antitrypsin
Meds
FH
Smoking
Cocaine
Contact sports
Scuba diver
Planned flights
```
212
What does a swinging chest drain mean?
Drain is in pleural space
213
What advice should be given post pneumothorax?
```
Quit smoking
Return if symptomatic
Never scuba dive, unless pleurodesis
Flights: if chest X-ray confirms no pneumothorax 7 days before flying
Avoid contact sports for 6 weeks
```
214
What gives appearance of white out on chest X-ray?
Massive pleural effusion
Pneumonectomy
Total lung collapse
215
Who should be offered a FeNO test?
Adults in whom asthma is being considered
| Children and young people (5-16) if diagnostic uncertainty after initial assessment
