Respiratory

Question 1

Formula for the A-a gradient

Answer 1

Fio2(Ppatm-Ppwater vapour) - (PaCO2/0.8) - PaO2

Question 2

Causes of elevated A-a gradient

Answer 2

V/Q mismatch
Diffusion defect
Right to left shunt

Question 3

Causes of hyperaemia with a normal A-a gradient

Answer 3

Alveolar hypoventilation

Low Fio2

Question 4

Best predictive metric for IPF

Answer 4

FVC

Question 5

What is the UIP pattern on HRCT

Answer 5

Traction Bronchiectasis
Subpleural Reticulations with basal predominance
Honeycombing

Question 6

Two anti-fibrotic treatments considered in IPF

Answer 6

nintedanib and pirfenidone

Question 7

Main side effect of Pirfenidone

Answer 7

Photosensitivity

Question 8

In newly diagnosed asthma which will decrease exacerbations

Answer 8

ICS

Question 9

Main cause of death in patients with stable moderate-sever COPD with no comorbidites

Answer 9

Cardiovascular

Question 10

When should you consider introducing ICS in a patient with COPD

Answer 10

In the context of high eosinophil count

Question 11

In former smokers which Abx can reduce infective exacerbations?

Answer 11

Azithromycin

A/E
Hearing loss
Gastrointestinal upset

Question 12

Which intervention most effectively reduces disease progression in COPD?

Answer 12

Smoking cessation

Question 13

Diagnosis of COPD

Answer 13

FEV1/FVC <0.70 with no reversibility

Question 14

What is the most effective treatment in COPD to minima acute exacerbations, hospitalisations and symptoms?

Answer 14

LABA/LAMA combination

Note no improvement in underlying lung function
Also note that LAMA or LABA mono therapy is first line therapy

Question 15

What additional puffer do you add in to a patient who has experienced an exacerbation of COPD?

Answer 15

ICS

Note increased risk of pneumonia

Question 16

Antibiotics for infective exacerbation of COPD (fever, increased sputum production or change in sputum colour)

Answer 16

Doxycycline or Amoxicillin

+ Oral corticosteroids

Question 17

What is Romuliflast?

Answer 17

PD4 inhibitor –> anti-inflammatory effects

Has been shown to reduce acute exacerbations of COPD

Question 18

Effective strategies for smoking cessation

Answer 18

Pharmacological therapy + counselling

Nb: Combination NRT is more effective than single product

Question 19

What benefits does NIV in patients with COPD derived T2RF deliver?

Answer 19

1. Reduced intubation rates

2. Reduced hospital LOS

Question 20

Effect of long term NIV

Answer 20

Reduced admission free survival

But ? reduced quality of life

Question 21

Pharmacological addition in patients with COPD commencing palliative care treatment?

Answer 21

Daily long acting opioids (kapanol) + laxatives

Question 22

Significant post-bronchodilator response

Answer 22

FER increases by 200ml and 12%

Question 23

What feature is identifiable on PFT in gas trapping?

Answer 23

elevate RV/TLC

Question 24

What feature is identifiable on PFT in gas trapping?

Answer 24

Elevated RV/TLC

Question 25

Best test for negative predictive value in asthma?

Answer 25

Methacholine bronchoprovocation test 20% fall in Fev1 Fals positives in allergic rhinitis, CF, heart failure, COPD and bronchitis

Question 26

When is nitric oxide increased in FENO testing?

Answer 26

Eosinophilic asthma.

Question 27

Cardinal features of AVPA

Answer 27

1) Bronchiectasis on CT | 2) Elevated IgE

Question 28

Effect of ICS in asthma

Answer 28

Reduced airway remodelling Down regulation of pro-inflammatory proteins ICS = mainstay of treatment ICS --> ICS+LABA -->

Question 29

In which patients would you use Omalizumab in asthma?

Answer 29

Allergic Asthma (Positive RAST) with elevated IgE (IgE>30I/U)

Question 30

In which patients would you use Mepolizumab in asthma

Answer 30

Eosinophilic asthma - Peripheral eosinophils > 150/microL - Sputum eosinophils > 3% Mepolizumab monoclonal antibody to IL-5

Question 31

When to consider a surgical lung biopsy in possible ILD?

Answer 31

Age <50 Atypical HRCT Rapidly progressive disease Note 1-2% mortality of elective surgical lung biopsy

Question 32

Indications fort transplant in IPF

Answer 32

Patients <65 DLCO <40% FVC <80% Decrease in SPO2 88% (including on exertion) Dyspnoea or functional limitation attributable to lung disease

Question 33

CT findings in NSIP

Answer 33

Ground glass opacity Reticular Opacity Traction bronchiectasis Diffuse - can have sub pleural sparing

Question 34

Best investigation test for sarcoidosis

Answer 34

Endobronchial ultrasound guided hilar lymph node biopsy Supportive BAL: Elevated CD4:CD8

Question 35

Diagnosis of Pulmonary Arterial Hypertension

Answer 35

PAP: >20 PCWP >15 WU > 3

Question 36

Causes of pulmonary arterial hypertension

Answer 36

1) Connective tissues disease 2) HIV infection 3) Porta hypertension 4) Congenital heart disease 5) Schistosomiasis

Question 37

Heritable forms of PAH are usually associated with

Answer 37

BMPR2 - inhibits smooth muscle proliferation and induces apoptosis > Only 25% of patients with BMPR2 mutations > 70-80% of familial PAH have BMPR 2 mutation (autosomal dominant with incomplete penetrance and variable expressibility)

Question 38

What predicts mortality in patients with IPAH

Answer 38

Hypocapnea RVEF <35% PVR > 650 wood units

Question 39

Which patients should be offered CCB in PAH type w1

Answer 39

Those who response to inhaled NO or IV epoprostenol | > MPAP >10mmhg drop then <40

Question 40

Initial therapy for PAH?

Answer 40

Ambrisentan + Tadalafil

Question 41

Initial testing for bronchiectasis (incomplete)

Answer 41

1) FBC/UEC 2) IGE + Specific IgE to Aspegillus 3) Immungolbuins 4) Sputum MCS + AFB

Question 42

Treatment for frequent exacerbates (>3 or more exacerbations in the past 12 months)

Answer 42

Azithromycin > Note QT prolongation (do ECG) or Erythromycin

Question 43

In CF colonisation with which organism predicts for worse outcomes?

Answer 43

Burkholderia

Question 44

Which subset of patients in CF benefit from Ivacaftor

Answer 44

G551D-CFTR mutation

Question 45

Which subset of patients in CF benefit from Ivacaftor + Elexacaftor + Tezecaftor

Answer 45

Delta 508 Homozygotes/Heterozygotes

Question 46

When to consider transplant in CF`

Answer 46

``` FEV1<30% Rapid decline Malnutrition + Diabetes Frequent exacerbations Relapsing or complicated pneumothorax ICU admission Recurrent haemopytisis ```

Question 47

Indication for Omalizumab

Answer 47

Asthma with elevated IGE ("In law grandma edna - Oma)

Question 48

Diagnosis of ABPA

Answer 48

1) Predisposing condition - Asthma - CF 2) Obligatory criteria - Positive skin prick test or increased IGE levels to Aspergillus - Elevated IgE concentration (>1000) 3) Other (2 must be present) - Positive aspergillus precipitants or elevated IgE to A Fumigatus - Radiology consistent with ABPA - Total eosinophil count >0.5x10 in steroid naive patiens