Respiratory

Question 1

what are the classic features of Asthma

Answer 1

wheezing and episodic SOB, worse at night/on exercise, cough/nocturnal cough, tight chest, decreased FEV1 relieve by B2 agonist

Question 2

what factors should be specificall asked about in Asthma history taking

Answer 2

Precipitants (cold air, exercise, emotion, allergens, infection, drugs), diurnal variation in symptoms and peak flow (morning dip of peak flow common), exercise tolerance, acid reflux (known association with asthma), other atopic disease/family hx atopy, home (pets/carpet, feathered furnishings), occupation, days per week off school/work, how often waking up at night (sign of serious asthma)

Question 3

what are the typical features of occupational asthma?

Answer 3

something at work triggering, better at weekends/holidays, not necessarily getting better in evenings as can last hours after trigger

Question 4

what are some of the most common precipitants of an asthma attack?

Answer 4

environmental allergens (house dust mite, grass pollen, pets), cold air, emotion, viruses (rhinovirus, parsinfuenza, RSV), atmospheric pollution (sulphur dioxide, ozone, particulate matter), drugs (NSAIDS, B-Blockers), dusts/vapour and fumes (eg perfumes, cigarette smoke)

Question 5

what are the differences between extrinsic and intrinsic asathma

Answer 5

extrinsic, mostly early onset, most frequent in atopic individuals. Can develop late onset, especially from causes such as occupational agents, aspirin intolerence or B2-adrenoreceptor agonists for hypertension/angina)

Intrinsic, usually late onset, often middle age, no causitive agent can be identified but cold exposure and exertion may trigger

Question 6

what are the typical features of an acute severe asthma attack

Answer 6

RR >25 breaths/minute, tachycardia, PEF < 50% of predicted normal/best, widespread expiratory wheeze, inability to complete sentence in one breath, pulsus paradoxus

Question 7

what are the typical features of a life-threatening asthma attack

Answer 7

silent chest, cyanosis, feeble respiratory effort, exhaustion, confusion, coma, bradycardia/hypotension, PEF <30% normal/best or 150L/min

Question 8

what might the ABG findings of a severe asthma attack be?

Answer 8

High PaCO2 >6kPa, severe hypoxaemia (PaO2 < 8kpa despite O2 therapy, low and falling arterial pH

Question 9

what is pulsus paradoxus

Answer 9

abnormal fall in bp on inspiration. Normally SBP and pulse pressure (SBP-DBP) fall during inspiration due to increased pulmonary intravascular volume but not more than 10mmHg

Question 10

what conditions may pulsus paradoxus be present

Answer 10

respiratory, pulmonary embolism
tension pneumothorax
asthma
chronic obstructive pulmonary disease

cardiac Peridcardial effusion, cardiac tamponade
constrictive pericarditis
pericardial effusion
cardiogenic shock

Question 11

explain the cellular mechanisms involved in asthma

Answer 11

T1 hypersensitivity, mast cells release histamine, T cells (particularly Th2) in the mucosal cellular infiltrate release IL-4 and IL-13, eosinophiles migrate in response to chemotactic factors releasing leukotrienes (LTC4 and LTD4), these constrict airways and likely are responsible for remodelling bronchii. Stimulation of afferent nerves, release of local neuropeptides which mediate odema and mucus hypersecretion, inflammation of bronchial wall causing airflow restriction by depletion of surfactant in small airways making opening difficult.

Question 12

what will be the physiological features of lungs with chronic asthma

Answer 12

bronchoconstriction (increased responsiveness of bronchial smooth muscle), hypersecretion of mucus and mucus plugging, mucosal odema (narrowing of airway lumen), infiltration of bronchial mucosa by eosinophils, mast cells, lymphoid cells and macrophages, focal necrosis of airway epithelium, collagen deposition beneath bronchial epithelium in long standing cases, sputum containing charcot-leyden crystals from eosinophil granules and curshman spirals (mucus plugs from small airways(

Question 13

Early phase asthma is characterised by …..

Answer 13

Early phase asthma is characterised by production of spasmogens (histamine, prostaglandin D2, leukotrienes C4 and D4 leading to bronchospasm

Question 14

… is characterised by production of spasmogens (histamine, prostaglandin D2, leukotrienes C4 and D4 leading to bronchospasm

Answer 14

Early phase asthma is characterised by production of spasmogens (histamine, prostaglandin D2, leukotrienes C4 and D4 leading to bronchospasm

Question 15

Late phase asthma is characterised by ……

Answer 15

Late phase asthma is characterised by production of chemotaxins (LB4, PAF) which attract leukocytes, especially eosinophils and mononuclear cells leading to inflammation of airway and hyperreactivity

Question 16

…… is characterised by production of chemotaxins (LB4, PAF) which attract leukocytes, especially eosinophils and mononuclear cells leading to inflammation of airway and hyperreactivity

Answer 16

Late phase asthma is characterised by production of chemotaxins (LB4, PAF) which attract leukocytes, especially eosinophils and mononuclear cells leading to inflammation of airway and hyperreactivity

Question 17

what is the definition of COPD?

Answer 17

Airflow limitation that is not fully reversible, usually progressive and associated with abnormal inflammatory response of lungs to noxious particles

Question 18

What are the 3 main pathologies contributing to COPD

Answer 18

emphysema (destruction of air spaces and loss of elastic recoil), chronic bronchitis (mucus hypersecretion and luminal narrowing of airways) and bronchiolitis (narrowing of small airways by inflammation/scarring)

Question 19

how would emphysema be defined

Answer 19

permanent dilation of any part of the respiratory acinus (distal to terminal bronchiole) with destruction of tissue in the absence of scarring

Question 20

what are the pathalogical features of emphysema

Answer 20

parenchymal destruction by extracellular proteases due to reduction of normal defensive protease inhibitors, loss of elastic recoil as connective tissue in alveolar walls is destroyed, reduction in area available for gas exchange. Reduced O2 uptake despite increased ventilation. Maintain O2 blood level but become breathless on slightest exertion and become hypoxic (T1 resp failure). Large, voluminous lungs with large, dilated air spaces

Question 21

What are the 2 main forms of emphysema? what are their characteristics?

Answer 21

Centriacinar, most common, most cases smoking related, most often in upper lobes, dilation of respiratory bronchioles at centre of respiratory acinus, dilated air spaces surrounded by normal alveoli

Panacinar, involves whole respiratory acinus, first affecting terminal alveoli and alveolar ducts, associated with smoking but more with a1 trypsinase deficiency, affects both upper and lower lobes

Question 22

how is chronic bronchitis defined?

Answer 22

productive cough on most days for 3 months of year for at least 2 succesive years

Question 23

what is the pathogenesis of chronic bronchitis

Answer 23

secretion of abnormal amounts of mucus causing plugging and narrowing of airway lumen, hypertrophy and hyperplasia of bronchial mucus glands, inflammation typically not present although may occur from repeated RTI, can lead to squamous metaplasia in pts with repeated infections. This leads to alveolar hypoventilation, hypoxaemia and hypercapnia (T2 RF). Individuals will typically be cyanosed but not usually having distressing dyspnoea. Hypoxic pulmonary vasoconstriction may cause hypertension and RHF (cor pulmonale)

Question 24

hereditary a1 antitrypsin deficiency accounts for around … of emphysema cases

Answer 24

2%

Question 25

what proportion of pts with COPD smoke(d)?

Answer 25

90%

Question 26

what are the risk factors for COPD

Answer 26

``` Cigarette smoke Age older than 40 years Exposure to occupational dust and chemicals Exposure to indoor air pollution Alpha-1 antitrypsin deficiency ```

Question 27

what features differentiate COPD from asthma

Answer 27

age >35, smoking, dyspnoea is constant, no marked diurnal/day to day variation, sputum production

Question 28

what are the typical symptoms of somebody with COPD?

Answer 28

Cough, sputum production, wheeze, breathlessness, frequent chest infections, worsened by cold/foggy weather/pollution, severe breatlessness even with mild exercise

Question 29

what will be the clinical findings in somebody with COPD

Answer 29

wheeze throughout chest, tachypnoeic with prolonged expiration, use of accesory muscles, intercostal indrawing on inspiration and pursing of lips on expiration, hyperinflated lungs, hyperresonance on percussion of liver and heart, barrel shaped chest, tracheal tug With hypercapnia, peripheral vasodilation, bounding pulse, CO2 flap

Question 30

what will be the clinical findings in somebody with Asthma

Answer 30

audiable, widespread polyphonic wheeze, hyper-inflated chest

Question 31

what should be the ABG findings in a patient suffering an acute asthma attack?

Answer 31

normal/slightly reduce PaO2 and reduced PaCO2. If PaCO2 is raised transfer to HDU/ITU for ventilation

Question 32

what will a chest xray be used for in asthma

Answer 32

exclude pneumothorax/infection

Question 33

what will be the clinical features of a pt with bronchiectasis

Answer 33

copious amounts of purulent (bad smelling discoloured) sputum, recurrent cough and infections, intermittent haemoptysis

Question 34

what may be the clinical findings of a patient with bronchiectasis

Answer 34

clubbing, course inspiratory crackles over infected areas, wheeze

Question 35

what investigations may be performed on a pt with bronchiecstasis

Answer 35

sputum culture, CXR, HRCT chest, spirometry (showing obstructive pattern), bronchoscopy to locate site of haemoptysis and exclude obstruction, CF sweat test, serum immunoglobulins

Question 36

what are some of the common causes of bronchiecstasis

Answer 36

Congenital (young's syndrome, Kartagener's syndrome, post infective (measles, TB, pneumonia, sarcoidosis, immunological post-lung transplant and allergic bronchopulmonaryaspergillosis, immune deficiencies (primary and IgA and IgG2)

Question 37

symptoms of pneumonia

Answer 37

Fever/rigor, dyspnoea, malaise, nausea, productive cough, haemoptysis, pleuritic chest pain

Question 38

what will be the signs of pneumonia on examination of the chest

Answer 38

diminished expansion, dull percussion, increased tactile vocal fremitus/resonance, bronchial breathing, pleural rub

Question 39

explain the CURB65 criteria for assessing severity of Pneumonia

Answer 39

Confusion, Urea > 7 mmol/l RR >30 BP65 0 or 1 likely suitable for home treatment and oabx 2, hospital treatment >3 assess for ICU

Question 40

what organisms commonly cause CAP

Answer 40

Strep pneumonaie most common, then H.Influenzae (spcially in elderly with comorbidities eg COPD), mycoplasma pneumoniae, staph aureus, legionella (specially if foreign travel), Moraxella catarhallis and chlamydia. chlamydia and myc oplasma common in young rare in elderly. Rarely gram -ve/anaerobes rare, viruses in about 15%

Question 41

what organisms commonly cause HAP

Answer 41

most commonly g-ve enterobacteria and staph aureus, less commonly E.Coli, klebsiella, pseudomonas, bacteriodes and clostridia

Question 42

What abx would be chosen for pt with CAP

Answer 42

mild, oral amoxicillin AND eryth or fluoroquinalone. Ampicillin/eryth if IVI req severe; IV co-amox or cephalosporin eg cefuroxime and eryth

Question 43

what abx would be chosen for HAP

Answer 43

aminoglyclaside (eg gent) AND antipseudomonal penicillin IV or 3rd gen cephalosporin

Question 44

what factors predispose to pneumonia

Answer 44

viral infection with influenza/parainfluenza(staph aureus), hospitalised, smoking, alcohol excess, bronchiectasis, bronchial obstruction, immunosuppression, IV drugs, oesophageal obstruction, pets, travel

Question 45

what is the typical presentation of pneumothorax

Answer 45

possibly nothing if small, sudden onset pleuritic pain, progressively increasing breathlessness, sudden deterioration COPD/Asthma

Question 46

What might be the signs in somebody with pneumothorax

Answer 46

Pallor, tachy, reduced expansion on affected side, reduced/absent breath sounds, increased resonance on percussion, decreased/absent vocal resonance, tracheal deviation away from affected side in tension pneumothorax.

Question 47

what are the typical risk factors of pneumothorax

Answer 47

asthma, COPD, TB, pneumonia, lung abscess, carcinoma, CF, lung fibrosis, ehlers-danlos, marfans, trauma,

Question 48

what are the main histological types of lunc carcinoma and their incidence

Answer 48

squamous cell (50%), adenocarcinoma inc bronchoalveolar (20%), small cell/oat cell anaplastic (20%), large cell anaplastic (10%) Clinically generally separated into small cell and none-small cell due to prognosis/treatment differences

Question 49

what is the mean survival rate in pts with none small cell LC

Answer 49

50% 2 year survival without spread, 10% with

Question 50

what is the mean survival rate in pts with SCLC

Answer 50

median survival less than 3 months if untreated, 1-1.5 years treated

Question 51

What are the causes of SOB

Answer 51

Lungs -airways (Asthma/COPD/Tumours/Bronchiectasis) - Parenchyma (atypical pneumonia/TB, fibrosis (pneumoconiosis/asbestos/all alveolitis), inflammatory (sarcoid/RA/Lupus) - Circulation (PE/vasculitis) - Pleural (pneumothorax/Pleural effusion/asbestos) Cardiac (Failure, myopathy, mitral valve disease, constrictive pericarditis) Neuromuscular (G.Barre, M.Gravis) Structural (kyphoscoliosis)

Question 52

What are the criteria of CURB65 score. How do they relate to severity?

Answer 52

Confusion (AMT 7, resp >30, BP 65 score of 5, risk of death 27.8%, 0.6% 0-1, treat as OP, oral amoxy/clarith 2-3, consider hospital 4-5, hospital plus consider ITU Mild oral amoxy/macrolide (claryth), sever but won't go to hospital offer both, severe in hospital plus IV B-lacamase (co-amox) plus macrolide

Question 53

what are the commonest causes of bronchiectasis

Answer 53

childhood infections (whooping cough, measles, pneumonia), CF, allergic bronchopulmonary aspergillosus often associated with Asthma)

Question 54

features of churg strauss

Answer 54

Asthma, eosinophilia, mono/polyneuropathy, spots/lesions on CXR, sinus probs, WBC outside blood vessel (from tissue sample) Any 2 of above. Antibodies blood test can also be done

Question 55

What are the criteria for Churg-Strauss syndrome

Answer 55

Any 2/3 of Asthma, eosinophilia, mono/polyneuropathy, spots/lesions on CXR, WBC outside blood vessels (from biopsy). Anbody blood test can also be done

Question 56

What is the treatment regime for TB

Answer 56

Rifampicin, isoniazid (6/12), 2 additional pyrazinamide and ethambutol daily 2/12 Extrapulmonary TB may be longer and steroids eg brain

Question 57

How can somebody with TB expect to recover

Answer 57

Usually not infectious after about 2/52, may be weeks/months before feeling better and important to take course as directed as resistance will mean longer course of druges. Rare to return if treatment taken as advised

Question 58

When should latent TB be treated

Answer 58

<35, HIV, healthcare worker, scars on CXR

Question 59

What advice should be given regarding side effects/interactions of TB medication

Answer 59

Rifampicin interacts with COCP, use other protection May rarely damage liver, LFTs before starting and monitor. Ethambutol can cause eye damage. Contact if being sick, yellow skin/eyes, tingling hands/feet, rash, blurred/altered vision, unexplained fever