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Finals > Respiratory from Passmed > Flashcards

Respiratory from Passmed Flashcards

1
Q

types of fibrosis that typically affect the upper zones

A

CHARTS

  • Coal worker’s pneumoconiosis
  • Histocytosis/Hypersensitivity pneumonitis
  • Ank spon
  • Radiation
  • Tuberculosis
  • Sarcoid/Silicosis
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2
Q

fibrosis causes that predominantly affect the lower zones

A

idiopathic pulmonary fibrosis

most connective tissue disorders EXCEPT ank spon (so like SLE)

drug induced

asbestosis

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3
Q

drugs that cause fibrosis

A

amiodarone

bleomycin

methotrexate

nitrofurantoin (and other abx).

chemo drugs

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4
Q

three things you can prescribe as part of smoking cessation

A

NRT

Varenicline

Buproprion

they should not be prescribed in combination with each other

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5
Q

what poisoning is associated with resp alkylosis

A

salicylate

salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis

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6
Q

key indications for NIV

A
  • COPD with respiratory acidosis pH 7.25-7.35
    • can be used if more acidotic but they need HDU and lower threshold for intubation
  • type II resp failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
  • cardiogenic pulmonary oedema unresponsive to CPAP
  • weaning from tracheal intubation
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7
Q

what are the recommended initial settings for bi-level pressure support in COPD

A
  • EPAP: 4-5cm H2O
  • IPAP: 10-15cm H2O
  • back up rate 15 breaths/min
  • back up inspiration:expiration ratio: 1:3
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8
Q

hypercalcaemia + bilateral hilar lymphadenopathy = ?

A

sarcoidosis

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9
Q

most common organisms that cause infective exacerbations of COPD

A

Haemophilus influenzae (most common cause)

Streptococcus pneumoniae

Moraxella catarrhalis

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10
Q

treatment for infective exacerbation of COPD

A
  • increase frequency of bronchodilator use and consider giving via a nebuliser
  • give prednisolone 30 mg daily for 5 days
  • oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’
    • the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
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11
Q

what is varenicline

A
  • nicotinic receptor partial agonist
  • start 1 week before they stop smoking
  • recommended course is 12 weeks
  • nausea is most common adverse effect
  • caution in pts with self-harm/depression history
  • contraindicated in pregnancy and breastfeeding
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12
Q

what is bupropion

A

a norepinephrine and dopamine reuptake inhibitor and nicotinic agonist

  • start 1-2 weeks before stop smoking date
  • 1 in 1000 risk of seizures
  • contraindicated in
    • pregnancy
    • epilepsy
    • breast feeding
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13
Q

management of smoking in pregnancy

A
  • All women are CO tested
  • anyone with CO of 7ppm or more referred to NHS stop smoking
  • first line
    • CBT
    • NRT
  • note that varenicline and bupropion are contraindicated in pregnancy
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14
Q

COPD management flow diagram

A
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15
Q

criteria to determine whether a patient has asthmatic features of COPD

A
  • any previous, secure diagnosis of asthma or of atopy
  • a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
  • substantial variation in FEV1 over time (at least 400 ml)
  • substantial diurnal variation in peak expiratory flow (at least 20%)
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16
Q

when can you fly after a pneumothorax

A

one week after a CXR shows complete resolution of the pneumothorax

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17
Q

what is catamenial pneumothorax

A

Catamenial pneumothoraces are pneumothoraces that occurs in association with menses, secondary to thoracic endometriosis

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18
Q

management of primary pneumothorax

A
  • patient not breathless AND rim <2cm from chest wall
    • consider discharge
  • OTHERWISE
    • aspiration attempted
  • if this fails
    • defined as >2cm or pt still SOB
    • insert chest drain
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19
Q

management of secondary pneumothorax

A
  • if pt >50 and/or rim >2cm and/or they are short of breath
    • chest drain
  • otherwise if rim 1-2cm aspirate
  • if aspiration fails then chest drain
  • if rim <1cm then give oxygen and admit for observation
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20
Q

what are the 3 types of altitude related disorders

A

acute mountain sickness (AMS) which may progress to high altitude pulmonary edema (HAPE) or high altitude cerebral edema (HACE)

all caused by chronic hypobaric hypoxia which develops at high altitudes

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21
Q

management of HACE

A

high altitude cerebral oedema

descent and dexamethasone

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22
Q

management of HAPE

A

high altitude pulmonary oedema

descent

nifedipine, dexamethasone, acetaxolamide (all work by reducing systolic pulmonary artery pressure)

oxygen if available

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23
Q

multiple, round well-defined lung secondaries seen on CXR are often referred to as _____ and they are most commonly seen in which type of cancer

A

these are cannonball mets

they are most commonly seen in renal cell cancer but can also be secondary to choriocarcinoma and prostate cancer

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24
Q

what is the grading system for COPD

A
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25
Q

what is histoplasmosis and what are the typical CXR findings

A

fungal lung disease

CXR shows unilateral or bilateral interstitial or reticulonodular infiltrates

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26
Q

blood test that can help diagnose sarcoid

A

serum ACE is raised in approximately 60% of sarcoid patients at diagnosis

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27
Q

where would you insert the chest drain for a pleural effusion?

A
  • The triangle of safety actually has four sides
    • The base of the axilla (superior boundary)
    • Lateral edge of the pectoralis major (medial boundary)
    • 5th intercostal space (inferior boundary)
    • Anterior border of latissimus dorsi (lateral boundary).
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28
Q

what are the pleural plaques seen on CXR of pts with exposure to asbestos

A
  • Pleural plaques are most common form of asbestos-related lung disease
  • Are benign.
  • Indicate the patient has been exposed to asbestos 20-40 years prior
    • this could put them at a higher ris of mesothelioma but the plaques themselves are not premalignant and don’t require monitoring
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29
Q

what spirometry findings are there in asbestosis

A

FEV1 is reduced

FVC is SIGNIFICANTLY reduced

therefore it’s: FEV1 reduced, FEV1/FVC - normal or increased

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30
Q

what effect does ankylosing spondylisis have on pulmonary function tests

A

FEV1 and FVC are both reduced but the ratio remains normal or increased

  • this is because of
    • apical lung fibrosis
    • thoracic kyphosis and reduced chest wall expansion
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31
Q

what is the treatment for allergic bronchopulmonary aspergillosis

A

oral glucocorticoids

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32
Q

which patients with COPD should be considered for prophylactic treatment with azithromycin?

A

criteria are as follows

  • do not smoke
  • have optimised all other therapies including inhaled, vaccinations, rehab
  • continue to have one or more of the following
    • frequent exacerbations (4 or more per year)
    • prolonged exacerbations with sputum production
    • exacerbations resulting in hospitalisation
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33
Q

why does FeNO testing work for asthma

A

Nitric oxide is produced by 3 types of nitric oxide synthases (NOS). One of the types is inducible (iNOS) and levels tend to rise in inflammatory cells, particularly eosinophils. Levels of NO therefore typically correlate with levels of inflammation.

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34
Q

what tests to diagnose asthma in an adult

A

Spirometry with reversibility

FeNO

35
Q

what is the criteria of reversibility in a diagnosis of asthma

A

>12% increase in FEV1

this must also be an absolute increase in FEV1 of 200ml

36
Q

where is alpha-1 antitrypsin made

A

in the liver - that’s why deficiency damages the liver as it accumulates there

37
Q

what is allergic bronchopulmonary aspergillosis

A
  • it is an allergy to aspergillus spores
  • it often occurs with a history of bronchiectasis and eosinophilia
  • features include
    • bronchosonstriction
      • possibly with previous label of asthma
    • bronchiectasis
  • management is with oral glucocorticoids
    • triconozole is sometimes used as second line
38
Q

what is dextrocardia

A

condition in which the heart is pointed toward the right side of the chest

it presents with quiet heart sounds and small volume complexes in the lateral leads

39
Q

what is kartagener’s syndrome

A
  • rare, autosomal recessive genetic ciliary disorder comprising the triad of:
    • situs inversus or dextrocardia
    • chronic sinusitis
    • bronchiectasis
40
Q
A
41
Q

what is acute bronchitis

A

usually viral

occurs generally in autumn and winter

usually self limiting

inflammation of the trachea and major bronchi and is therefore associated with oedematous large airways and the production of sputum

42
Q

differentiating acute bronchitis from pneumonia

A

History: Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.

Examination: No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze. Moreover, systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.

43
Q

when should you consider antibiotics in acute bronchitis

and what abx should you choose

A
  • if patients are very unwell systemically
  • have pre-existing co-morbidities
  • have high CRP above 100

doxycycline is first line

44
Q

what are the indications for steroids in sarcoidosis

and what steroids would you prescribe

A
  • patients with chest x-ray stage 2 or 3 disease AND who are symptomatic.
  • hypercalcaemia
  • eye, heart or neuro involvement

prescribe oral prednisolone

45
Q

X ray findings in heart failure

A
  • ABCDE
    • Alveolar oedema (bat wings)
    • kerley B lines (interstitial oedema)
    • Cardiomegaly
    • Dilated prominent upper lobe vessels
    • Effusion (pleural)
46
Q

management of pleural effusion

A
  • US guided aspiration
  • 21G needle and 50ml syringe
  • fluid sent for:
    • pH
    • protein
    • lactate
    • cytology
    • microbiology
47
Q

name two syndromes associatted with sarcoidosis

A
  • lofgren’s syndrome
    • acute form of disease
    • bilateral hilar lymphadenopathy
    • erythema nodosum
    • fever polyarthralgia
    • excellent prognosis
  • heerfordt’s syndrome
    • uveoparotid fever secondary to sarcoidosis
    • parotid enlargement
    • fever
    • uveitis
48
Q

features of sarcoidosis

A

acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
insidious: dyspnoea, non-productive cough, malaise, weight loss
skin: lupus pernio
hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)

49
Q

what organism often causes cavitating pneumonia in the upper lobes and is also commonly seen in patients with a history of alcohol abuse or diabetes

A

klebsiella pneumoniae

50
Q

how do large emphesematous bullae appear on cxr and what might they be mistaken for

A

they appear as lucent areas without a visible wall

they are commonly mistaken for pneumothoraces

51
Q

what are pneumatoceles

A

Pneumatoceles are intra-pulmonary air filled cystic spaces, usually caused as a result of ventilator induced lung injury. Pneumatoceles appear as a lucency with a thin wall on cxr.

52
Q

lung cancer that produces lambert-eaton syndrome, cushings and hyponatraemia is likely what type of lung cancer

A
  • small cell lung cancer has the following paraneoplastic features
    • ectopic acth production –> cushings
    • ectopic adh production –> dilutional hyponatraemia
53
Q

lung cancer that produces hypercalcaemia is likely what type of lung cancer

A

squamous cell lung cancers produce parathyroid hormone related protein leading to hypercalcaemia

54
Q

what are the steps for asthma management

7 steps

A
  1. Newly-diagnosed asthma
    • Short-acting beta agonist (SABA)
  2. Not controlled on previous step OR new asthma with symptoms 3 times a week or night-time waking
    • SABA + low-dose ICS
    • SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
    • SABA + low-dose ICS + long-acting beta agonist (LABA)
    • Continue LTRA depending on patient’s response to LTRA
    • SABA +/- LTRA
    • MART that includes a low-dose ICS
    • SABA +/- LTRA + medium-dose ICS MART
    • OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
    • SABA +/- LTRA + one of the following options:
      • increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART)
      • a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline)
      • seeking advice from a healthcare professional with expertise in asthma
55
Q

What is MART

A
  • Maintenance and reliever therapy
    • combined ICS and LABA
    • used as both maintenance and reliever as required
56
Q

first line abx for infective exacerbation of COPD

A

doxycycline, clarithromycin or amoxicillin

think about pen allergy and local guidelines

57
Q

how to escalate care in asthma 6 steps

A
  1. Oxygen
  2. Salbutamol nebulisers
  3. Ipratropium bromide nebulisers
  4. Hydrocortisone IV OR Oral Prednisolone
  5. Magnesium Sulfate IV
  6. Aminophylline/ IV salbutamol
58
Q
A
59
Q

what are centor criteria and what do they mean

A
  • The Centor criteria* are as follows:
    • presence of tonsillar exudate
    • tender anterior cervical lymphadenopathy or lymphadenitis
    • history of fever
    • absence of cough
  • *if 3 or more of the criteria are present there is a 40-60% chance the sore throat is caused by Group A beta-haemolytic Streptococcus
60
Q

when should you assess patients with COPD for long term oxygen therapy

A
  • Assess patients if any of the following:
    • FEV1 < 30% predicted
    • cyanosis
    • polycythaemia
    • peripheral oedema
    • raised jugular venous pressure
    • oxygen saturations less than or equal to 92% on room air
61
Q

how should you assess COPD patients for long term oxygen therapy

A
  • two abgs at least three weeks apart
  • offer if:
    • pO2 <7.3kPa
    • pO2 7.3-8kpa and one of the following
      • peripheral oedema
      • secondary polycythaemia
      • pulmonary hypertension
  • also assess for risk of fall from equipment
62
Q

in patients with exacerbations of COPD that is refractory to maximal medical treatment, which pH are they most likely to benefit from NIV

A
  • patients with a pH of 7.25-7.35 achieve the most benefit from BiPAP
  • if pH is less than 7.25 then they need invasive ventilation or BiPAP with HDU (more monitoring)
63
Q

if there’s lung cancer picture with gynaecomastia and pulmonary osteoarthropathy what kind of lung cancer is it?

A

adenocarcenoma

64
Q
A
65
Q

what is hypertrophic pulmonary osteoarthritis

A
  • syndrome characterised by triad of
    • periostitis
    • digital clubbijg
    • painful arthropathy of the large joints
  • can be caused by lung cancer
66
Q

what is the diagnostic test for obstructive sleep apnoea

A

polysomnography

67
Q
A
68
Q

how do you classify asthma attack severity

A
69
Q

how do you escalate treatment in asthma attacks

A
    1. Oxygen
    1. Salbutamol nebulisers
    1. Ipratropium bromide nebulisers
    1. Hydrocortisone IV OR Oral Prednisolone
    1. Magnesium Sulfate IV
    1. Aminophylline/ IV salbutamol
70
Q

differentials for early post-operative SOB

A

atelectasis, pneumonia and pulmonary embolism

atelectasis is the most common and is treated with physio and deep breathing exercises

71
Q

what are some things that cause anterior mediastinum masses

A

The commonest causes of an anterior mediastinum mass can be remembered by the 4 T’s: teratoma, terrible lymphadenopathy, thymic mass and thyroid mass

72
Q

how do you manage small cell lung cancer

A
  • usually metastatic disease by time of diagnosis
  • patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery. NICE support this approach in their 2011 guidelines
  • however, most patients with limited disease receive a combination of chemotherapy and radiotherapy
  • patients with more extensive disease are offered palliative chemotherapy
73
Q

5 steps in inhaler technique

A
  1. Remove cap and shake
  2. Breathe out gently
  3. Put mouthpiece in mouth and as you begin to breathe in, which should be slow and deep, press canister down and continue to inhale steadily and deeply
  4. Hold breath for 10 seconds, or as long as is comfortable
  5. For a second dose wait for approximately 30 seconds before repeating steps 1-4.
74
Q

All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling - when should this be done with a chest tube?

A
  • if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
  • if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
75
Q

what is acute respiratory distress syndrome?

A

Acute respiratory distress syndrome (ARDS) is caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema. It is a serious condition that has a mortality of around 40% and is associated with significant morbidity in those who survive.

76
Q

6 causes of ARDS

A
  • infection: sepsis, pneumonia
  • massive blood transfusion
  • trauma
  • smoke inhalation
  • acute pancreatitis
  • cardio-pulmonary bypass
77
Q

diagnostic criteria of ARDS

A
  • acute onset (within 1 week of a known risk factor)
  • pulmonary oedema: bilateral infiltrates on chest x-ray (‘not fully explained by effusions, lobar/lung collapse or nodules)
  • non-cardiogenic
  • pO2/FiO2 < 40kPa (200 mmHg)
78
Q

management of ARDS

A
  • due to the severity of the condition patients are generally managed in ITU
  • oxygenation/ventilation to treat the hypoxaemia
  • general organ support e.g. vasopressors as needed
  • treatment of the underlying cause e.g. antibiotics for sepsis
  • certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS
79
Q

What are 4 situations in which oxygen therapy is not indicated unless there is evidence of hypoxia

A
  • myocardial infarction and acute coronary syndromes
  • stroke
  • obstetric emergencies
  • anxiety-related hyperventilation
80
Q

advice for patients on how long URTIs will take to resolve

A
  • acute otitis media: 4 days
  • acute sore throat/acute pharyngitis/acute tonsillitis: 1 week
  • common cold: 1 1/2 weeks
  • acute rhinosinusitis: 2 1/2 weeks
  • acute cough/acute bronchitis: 3 weeks
81
Q

when would you take an immediate antibiotic prescribing approach with

A
  • children younger than 2 years with bilateral acute otitis media
  • children with otorrhoea who have acute otitis media
  • patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
82
Q

what is the target oxygen saturation in acute asthma

A

94-98%

83
Q

what is meig’s syndrome

A

Benign ovarian tumour, ascites, and pleural effusion.

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