Respiratory

Question 1

Tx acute exacerbation of asthma

Answer 1

Oxygen 15L via non rebreathe mask

Salbutamol 5mg via oxygen driven nebuliser

Ipratropium bromide 0.5mg via nebuliser

Oral prednisolone 50mg or IV hydrocortisone 100mg (both if very ill)

IV magnesium sulphate (Senior decision)

aminophylline/theophylline (Senior decision)

No sedatives

CXR if suspecting pneumothorax/consolidation or if patient is very likely to require intermittent positive pressure ventilation

Question 2

what are features on an ABG that indicate a life threatening asthma attack

Answer 2

Normal PaCo2 - should be low due to hyperventilation

Severe Hypoxia

Low pH

Question 3

post recovery Tx for acute asthma exacerbation

Answer 3

Oral prednisolone for 5 days

Nebulised salbutamol/ipatropium until discharge

Chart PEF before and after nebs, at least 4 times daily whilst In hospital

Prior to discharge check inhaler technique, agree on a written asthma action plan and ensure GP follow up within 2 working days

Question 4

Tx for chronic asthma in primary care

Answer 4

1. SABA + ICS
   Used to be one each but this changed to pretty much everyone getting preventer inhalers
2. SABA + ICS + LABA
3. Increased ICS dose OR add LTRA
   If there has been no response to the LABA consider stopping it
4. Refer for specialist care

(anti IgE drugs, oral corticosteroids or B2 agonists)

Before specialist care you could increase ICS to high dose and add a theophylline or LAMA

Use of SABA >3 times a week indicates poor control and the care should be escalated

Question 5

side effects of SABAs

Answer 5

tachycardia
cramps
tremor
hypokalaemia

Question 6

Side effects of inhaled corticosteroids for asthma

Answer 6

oral candidiasis

pneumonia

Question 7

side effects of LTRAs for chronic asthma

Answer 7

Thirst

GI disturbance

Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis (EGPA))

Question 8

side effects of theophyllines

Answer 8

Similar to caffeine

Tremor

Headache

Arrhythmia

Tachycardia

Nausea

Insomnia

Question 9

Primary care tx for COPD

Answer 9

Patient education on recognizing an exacerbation early

Action plan/rescue medications for frequent exacerbators - Steroids/antibiotics

Lifestyle advice
Diet
Exercise
Smoking cessation

Medication
Level of inhaled medication depends on severity
SABA/SAMA should be given to everyone with a diagnosis to use when required

FEV1 >50% expected
SABA + LABA
If this is insufficient try SABA + LABA + ICS
If that still insufficient try LAMA + LABA + ICS
OR
LAMA (remove SABA)
If insufficient try LAMA + LABA + ICS

FEV1 <50%
LABA + ICS or
LAMA
For both if insufficient go to LABA + ICS + LAMA

Question 10

Specialist care tx for COPD

Answer 10

Pulmonary rehab
3 sessions a week for 6 weeks
Consider if there is functional disability from COPD
Increases exercise capacity, decreases breathlessness and increases QOL

Aminophylline/theophylline
Consider if triple therapy unsuccessful

Mucolytics

Nutritional supplements
If low BMI

Long term oxygen therapy  
Increases survival (3 year survival increases by >50%)

Question 11

indictions for long term oxygen therapy in COPD

Answer 11

<92% SpO2

FEV1 <30%

Cyanosis

Secondary polycythaemia

Cor pulmonale

Question 12

what are surgical options for COPD

Answer 12

Pleurectomy for recurrent pneumothoraxes

Bullectomy for isolated bullous disease

Lung volume reduction
Allows expansion of functioning lung

Question 13

indications for hospital admission in an acute exacerbation of COPD

Answer 13

Severe breathlessness

Rapid symptom onset

Acute confusion

Peripheral oedema

Cyanosis

Low O2 sats

Question 14

outpatient management of acute exacerbation of COPD

Answer 14

Increase dose/frequency of the SABA

30mg prednisolone for 7-14 days

Ensure osteoporosis prophylaxis for patients on >3 treatments per year

Abx if there is clinical signs of an infection

‘Safety net’ the patients afterwards by reviewing 6 weeks later to optimise medication

Question 15

inpatient managment of an acute exacerbation of COPD

Answer 15

Oxygen titration

If unknown aim for 88-92%

28% venturi mask on 4L

Management as per outpatient regime with oxygen/nebs

Question 16

Tx Bronchiectasis

Answer 16

Assess for rare but treatable causes (immune deficiencies)

Stop smoking

Physiotherapy
Inspiratory muscle training
Effective for non CF-related disease

Postural drainage
Twice daily
A way to drain mucus out the lungs by changing positions

Antibiotics for exacerbations

Immunisations

Bronchodilators in most cases

Surgery is rarely indicated as the disease is rarely confined to one lobe
Lobectomies used to be common – seen in OSCE patients a lot

Question 17

what sign on chest CT is typical in bronchiectasis

Answer 17

signet ring sign

Question 18

whats the most common organisms for infective exacerbations of COPD + bronchiectasis

Answer 18

1st = Hib

others: psuedomonas, klebsiella, strep pneumoniae

Question 19

Tx Cystic fibrosis

Answer 19

Chest
As per bronchiectasis
2 IVAbx used for exacerbations to decrease resistance
One often has pseudomonal cover
There may be azithrymycin prophylaxis
Mucolytics - DNAase nebulisers
Airway clearance devices - Acapella device
Lung transplant - If respiratory failure develops

GI
Pancreatic enzyme replacement - Creon
Fat soluble vitamin supplementation - ADEK
Liver transplant if there is advanced cirrhosis

Other
Diabetes treatment
Fertility treatment
Genetic counselling

Question 20

Tx non-severe CAP

Answer 20

Oral amoxicillin as OPC

Doxycycline if pen allergic

Question 21

Tx moderately severe CAP

Answer 21

Oral amoxicillin + clarithromycin IPC

Oral doxycycline if pen allergic

Question 22

Tx severe CAP

Answer 22

IV clarithromycin + co-amoxiclav in HDU

Pen allergic/MRSA suspected levofloxacin + vancomycin

Tx for at least 10 days

Question 23

Tx aspiration pneumonia

Answer 23

Treat based on CURB score and add metronidazole

Question 24

tx HAP

Answer 24

Assess MRSA risk factors 
Known colonisation  
Previous infection 
Long term line/catheter 
Admitted from nursing home with skin breaks  

Mild
Oral doxycycline

Severe
Oral co-trimoxazole

These patients should be discussed with microbiology

Question 25

what is the post discharge management of a pneumonia

Answer 25

ALL patients should have a follow up CXR in 6 weeks to see resolution of consolidation and to assess for any permanent damage Non-resolution raises the possibility of bronchial blockage due to carcinoma

Question 26

complications of pneumonia

Answer 26

Parapneumonic infusion Empyema Post-infective bronchiectasis Lung abscesses Clubbing Sepsis

Question 27

what is the mantoux test for and how do you interpret it

Answer 27

latent TB ``` >5mm - Positive in Immunosuppressed individuals Those with prior TB Recent contacts ``` >10mm Positive in Those at risk of TB >15mm Positive in any individual

Question 28

before treating TB what should be screened for

Answer 28

HIV/HEPB/C screening should be offered before starting treatment

Question 29

Tx Tb

Answer 29

2 months of rimapicin, izoniazid(+pyridoxine), ethambutol, pyrazinamide then 4 months of rifampicin and izoniazid (+pyridoxine) for a total of 6 months

Question 30

how does CNS involvement of Tb change the treatment time

Answer 30

CNS involvement = 12 months of dual therapy

Question 31

what is the close contact protocol with a confirmed case of Tb

Answer 31

all household members should be tested

Question 32

side effects of RIPE drugs for Tb

Answer 32

Rifampicin Abnormal LFTs Pink urine Isoniazid Peripheral neuropathy Encephalopathy Both rare when prophylactic pyridoxine co-prescribed Pyrazinamide Hepatotoxic Rare but severe Ethambutol Optic neuritis Assess with colour vision testing

Question 33

Tx tension pneumothorax

Answer 33

100% oxygen Large bore cannula into the 2nd intercostal space, mid-clavicular line Attach to a 3 way tap and 50ml syringe and aspirate until there is resistance or the patient coughs excessively Check with CXR May discharge if successful with follow up XRs 24 hours and 7 days after to assess resolution CXR Chest drain

Question 34

Tx simple pneumothorax

Answer 34

Rim of air <2cm and patient is not SOB Discharge Avoid strenuous exercise Interval CXR every 2 weeks until resolution Advise to quit smoking as this affects recurrence Primary/spontaneous + Rim of air >2cm, or patient SOB Attempt aspiration (2nd intercostal space method Failure/recurrence = chest drain CXR to confirm location Drain should be attached via tubing to the underwater seal which must be below the level of the patient Check drain is swinging with respiration, bubbling and CXR to make sure position is ok Recurrent (>2)/secondary, lack of resolution in 5 days First chest drain Then if that does not work a pleurectomy may be indicated Talc pleuridesis if not

Question 35

what advice should be given post pneumothorax

Answer 35

avoid flying for 6 weeks avoid diving permanently

Question 36

management for small cell lung cancer

Answer 36

Nearly always disseminated at presentation, may respond to chemo/radio Prophylactic cranial radiotherapy may be indicated

Question 37

management for non-small cell lung cancer

Answer 37

If >2cm from carina – surgical excision Also has to be peripheral enough with no lymph/metastatic spread Adjuvant chemo also done Curative radiotherapy done if there is poor respiratory reserve Chemo-radiotherapy for more advanced disease

Question 38

what are the neuroendocrine complications of small cell lung carcinoma

Answer 38

eaton-lambert syndrome SIADH Cushings

Question 39

Tx of empyema

Answer 39

Requires IVABx and chest drain

Question 40

Tx interstitial lung disease

Answer 40

Many cases will be unresponsive 20% respond to long courses of prenisolone Some patients are suitable for lung transplantation

Question 41

causes for upper zone fibrosis of the lung

Answer 41

CHARTS ``` C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis ```

Question 42

causes for lower zone fibrosis of the lung

Answer 42

idiopathic pulmonary fibrosis most connective tissue disorders (except ankylosing spondylitis) e.g. SLE, RA drug-induced: amiodarone, bleomycin, methotrexate asbestosis

Question 43

Treatment of acute extrinsic allergic alveolitis

Answer 43

Oxygen Prednisolone

Question 44

Long term Tx of extrinsic allergic alveolitis

Answer 44

Aim for prevention Face masks No exposure Long term prednisolone may give physiological improvement Established fibrosis not amenable to treatment Farmers lung is compensatable in the UK

Question 45

causes of extrinsic allergic alveolitis

Answer 45

Farmers lung Caused by micropolyspora Bird fanciers lungs Proteins in bird droppings Malt workers lung Aspergillus

Question 46

Tx OSA

Answer 46

``` Behavioural changes Let partner sleep first Sleep on side Weight reduction Avoid alcohol/tobacco ``` CPAP via mask 50% will not tolerate CPAP therefore: Intra-oral devices Daytime stimulants - Modafinol Upper airways surgery

Question 47

complications of OSA

Answer 47

Pulmonary hypertension and cor pulmonale Type 2 respiratory failure Hypertension and increased cardiac risk

Question 48

Tx for T1RF

Answer 48

Treat underlying cause High flow oxygen (60%) Consider assisted ventilation if PaO2 remains <8kpa despite 60% O2

Question 49

Tx for T2RF

Answer 49

Respiratory centre may be reliant on hypoxic drive so oxygen therapy should be given with care starting at 24% O2 and checking the ABG after 20 mins

Question 50

Tx for sarcoidosis

Answer 50

Simple analgesia NSAIDs Corticosteroids (occasional - only if symptomatic)

Question 51

respiratory causes of clubbing

Answer 51

Intrathoracic neoplasm ``` Supparative lung disease (lung disease that leads to a cough) Lung abscess CF Bronchiectasis Fungal infection ``` Interstitial lung disease