Respiratory

Question 1

What is the definition of chronic obstructive pulmonary disorder?

Answer 1

A progressive respiratory disorder characterised by an obstructive pattern:


FEV1 = <80% predicted

FEV1/FVC <0.7

Little to no reversibility

Question 2

What is COPD an umbrella term for?

Answer 2

Chronic Bronchitis - cough, sputum production on most days for 3 months of 2 successive years

Emphysema - histologically as enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls

Question 3

What are the risk factors for developing COPD?

Answer 3

Non-modifiable = genetics (alpha 1 antitrypsin deficiency)

Modifiable = SMOKING, environmental exposure e.g. coal, pollution

Question 4

What are the 3 main symptoms of COPD?

Answer 4

Wheeze
Dyspnoea
Cough + frothy white sputum production

Question 5

What are the signs of an exacerbation of COPD?

Answer 5

Resp - tachypnoea, hand flap (CO2 retention), quiet breath sounds, hyperressonance

Use of accessory muscles, tripodding

Cyanosis

Question 6

What is a pink puffer?

Answer 6

Breathless but not cyanosed

↑ alveolar ventilation but O2 cannot cross alveolar wall as efficiently due to thickening/fibrosis

T1RF

(emphysematous)

Question 7

What is a blue bloater?

Answer 7

Cyanosed but not breathless

↓ alveolar ventilation due to inflammation and ↑ mucous

T2RF + have a hypoxic drive to breath due to chronic CO2 retention

Question 8

What is the management of an acute exacerbation of COPD?

Answer 8

Neb salbutamol and ipratropium bromide

Titrated o2 - aim for 88-92%

Steroids

IV aminophylline if no response

Consider abx if infective symptoms

Question 9

When would NIV be considered in a patient with an acute exacerbation of COPD?

Answer 9

Resp rate >30

pH <7.35 and worsening despite treatment

Question 10

What is the long term pharmacological management of COPD?

Answer 10

1) SABA

2) FEV >50 = LABA or LAMA
FEV <50 = LAMA/LABA + ICS

3) all of it together

Question 11

What is the non-pharmacological long term management of COPD?

Answer 11

Smoking Cessation!!! Diet advice!!

Influenza + Pneumococcal Vaccine!!!

Pulmonary Rehabilitation

Long Term Oxygen Therapy

Ceiling of care
?Surgery

Question 12

When would long term oxygen therapy be considered for a patient with COPD?

Answer 12

if pO2 = <7.3 on >2 occassions >3 weeks apart

OR

7.3-8 + other conditions/symptoms e.g. cor pulmonale

Question 13

What are the 3 most common causative organisms for CAP?

Answer 13

Strep Pneumoniae
H. Influenzae
Moraxella Catarrhalis

Question 14

What are 3 atypical organisms for CAP?

Answer 14

Staph Aureus
Chlamydia
Mycoplasma Pneumoniae

Question 15

What is the CURB 65 score?

Answer 15

Confusion
Urea = >7
Respiratory rate = >30
Blood pressure = <90 mmHg
> 65

Question 16

How should the CURB 65 Score be interpreted?

Answer 16

0-1 = PO abx 
2 = Hospital 
3 = very bad

Question 17

When can a hospital acquired pneumonia be diagnosed? What are the 3 most common causative organisms?

Answer 17

within 48hr of admission

Gram-negative enterobacteria
Staph. aureus
Klebsiella
Pseudomonas

Question 18

Give 2 examples of causative organisms of pneumonia in an immunocompromised host

Answer 18

The normal CAP organisms

Pneumocystis Jiroveci

Aspergillus SPP

Question 19

How does pneumonia present?

Answer 19

Productive cough (greenish sputum) +/- blood

Shortness of breath

Feeling generally unwell - fever, rigors, anorexia

Pleuritic chest pain

Question 20

What signs could be elicited on a patient with pneumonia?

Answer 20

Consolidation - Coarse crackles, dull percussion, reduced chest expansion, bronchial breathing

Tachypnoea, tachycardia
cyanosis

Question 21

What is the management of CAP?

Answer 21

CURB 65

Moderate = PO amoxicillin/doxycyline/clarithromycin

severe = admit for IV abx

Question 22

What is the management of HAP?

Answer 22

Moderate = PO Co-Amox/ Doxycylcine/ Cefalexin

Severe = IV Piperacillin + Tazobactam, Meropenem, Ceftriaxone, Cefuroxime

Question 23

How can immunocompromised be protected against their specific pneumonias?

Answer 23

pneumococcal vaccine

give to:
>65
Chronic heart, liver, renal, lung conditions
Diabetes on meds
Immunocompromised

Question 24

What is the definition of interstitial lung disease?

Answer 24

Fibrosis or chronic inflammation within the parenchyma

leading to a restrictive pattern of breathing on spirometry

Question 25

What are the causes of upper lobe ILD?

Answer 25

APENT ``` Aspergillosis (malt worker) Pneumoconiosis (silica, coal) Extrinsic Allergic Alveolitis (pigeon) Seronegative (PAIR) TB ```

Question 26

What are the causes of lower lobe ILD?

Answer 26

STAIR ``` Sarcoidosis Toxins Asbestosis Idiopathic pulmonary fibrosis Rheumatological conditions (RA, SLE, Scleroderma) ```

Question 27

Give 6 toxins that may cause lower lobe ILD

Answer 27

``` Methotrexate Bleomycin Sulfalazine Azathoprine Amiodarone Nitrofurantoin ```

Question 28

what are the signs and symptoms of ILD?

Answer 28

Dyspnoea on exertion Non-productive, paroxysmal cough Clubbing, cyanosis, fine end-inspiratory crackles, ? weight loss

Question 29

Define extrinsic allergic alveolitis

Answer 29

Repeated inhalation of an allergen leads to a type III hypersensitivity reaction in the acute phase. prolonged and more chronic = type IV hypersensitivity reaction occurs leading to the formation of granulomas.

Question 30

Define idiopathic pulmonary fibrosis

Answer 30

Infiltration of inflammatory cells and fibrosis of the parenchyma. Unknown cause but common. For supportive and palliative care.

Question 31

What is the gold standard imaging to diagnose ILD?

Answer 31

High resolution computed tomography (HRCT chest)

Question 32

What is the FEV1/FVC seen in obstructive disease?

Answer 32

<70% or <0.7

Question 33

What is the FEV1/FVC seen in restrictive disease?

Answer 33

Normal to increased so >70%

Question 34

What is a pneumothorax and what is the difference between a primary and a secondary pneumothorax?

Answer 34

Air within the pleural cavity ``` Primary = no underlying lung condition Secondary = the patient has a pre-existing lung disease ```

Question 35

What are the risk factors for pneumothorax?

Answer 35

Non-modifiable: - Tall and slim - Underlying lung disease e.g. Asthma or COPD Modifiable: - Trauma - Invasive ventilation/ NIV - Smoking

Question 36

Give 4 symptoms of pneumothorax

Answer 36

Shortness of breath Pleuritic chest pain Reduced lung expansion Tracheal deviation if tension

Question 37

Give 3 signs of pneumothorax

Answer 37

Severe tachypnoea Mediasteinal shift hypotension

Question 38

How can a large pneumothorax be differentiated from a small on CXR?

Answer 38

large = >2cm visible rim between lung margin and chest wall at the level of the hilum

Question 39

How would a primary pneumothorax be managed in a patient <50?

Answer 39

Asymptomatic + small = o2, monitor and follow up CXR Symptomatic or large = Aspirate. IF this fails then insert a chest drain

Question 40

How would a secondary pneumothorax and/or a patient >50 be managed?

Answer 40

Small/asymptomatic = monitor + o2 Large/symptomatic = aspirate then chest drain if fails

Question 41

What is the location of the chest drain to manage a pneumothorax?

Answer 41

Mid-clavicular line 2nd/3rd intercostal space

Question 42

What is the management of a tension pneumothorax?

Answer 42

Emergency needle decompression! Get a cardiothoracic surgeons opinion

Question 43

Give a complication of pneumothorax

Answer 43

Surgical emphysema occurs when air/gas is located in the subcutaneous tissues (the layer under the skin).

Question 44

Which lung cancer is most associated with smoking and hypercalcaemia?

Answer 44

Squamous cell

Question 45

What are the 4 medications used in TB treatment? Give one side effect for them

Answer 45

RIPE Rifampicin - red/orange wee + hepatotoxic Isonazid - peripheral neuropathy Pyrazinamide - hyperuricaemia (gout) Ethambutol - blurred vision/reduced visual acuity

Question 46

Define bronchiectasis

Answer 46

Permanent dilation of the bronchi and bronchioles due to chronic infection

Question 47

What are the 5 main causes of bronchiectasis?

Answer 47

Post-Infection: Tuberculosis; HIV; Measles; Pertussis; Pneumonia Bronchial Pathology: Obstruction by foreign body or tumour Allergic Bronchopulmonary aspergillosis (ABPA) Congenital: Cystic fibrosis; Kartagener's syndrome; Primary ciliary dyskinesia; Young syndrome Hypogammaglobulinaemia

Question 48

What are the features of an acute moderate asthma attack?

Answer 48

Increasing symptoms but no signs of a severe attack PEFR 50-75%

Question 49

What are the features of an acute severe asthma attack?

Answer 49

PEFR 33-50% RR >25 HR >110 Can't speak in full sentences

Question 50

What are the features of an acute life threatening asthma attack?

Answer 50

``` PEFR <33% PaO2 <8 NORMAL PACO2 poor respiratory effort cyanosis exhaustion/unable to speak/change in conscious levels arrhythmia ```

Question 51

What are the features of an acute near fatal asthma attack?

Answer 51

The same as life threatening but they begin to retain CO2 so PaCO2 increases

Question 52

Describe the features of a safe asthma discharge bundle

Answer 52

Meds - Been on discharge medication for 12-24 hours, check inhaler technique, on PO and I corticosteroids * PEF >75% of best or predicted * Own PEF meter and written asthma action plan - Follow up in 2 days with GP, and in 4 weeks at respiratory clinic

Question 53

define COPD

Answer 53

progressive obstructive disorder of the airway Get an obstructive pattern of breathing = (fev1 <80% predicted; fev1/fvc <0.7 little or no reversibility It includes chronic bronchitis and emphysema.

Question 54

What does the COPD care bundle comprise of? (5)

Answer 54

1) assess inhaler technique 2) Rescue pack and mx plan 3) Smoking cessation advice and referral 4) Pulmonary rehab referral 5) Follow up within 72 hours