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step 2 Flashcards

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1
Q

FRC and TLC in obstructive vs restrictive lung disease

A

FRC and TLC increase in obstructive but decrease in restrictive

(normal 80-120%)
ratio >70% normal
decreased in obstructive, normal/increased in restrictive

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2
Q

FEV1 and FVC in obstructive vs restrictive lung disease

A

FEV1 decreased in both
FVC normal/decreased in obstructive but decreased in restrictive

(normal 80-120%)

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3
Q

Samter triad

A

patient presents with asthma, recurrent rhinosinusitis and allergy to NSAIDS (pseudoallergic reaction, not IgE mediated)

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4
Q

best initial investigation for asthma

A

pulmonary function testing (spirometry)

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5
Q

patient presents with symptoms of asthma but pulmonary function testing is normal. what investigation could you carry out next if still suspicious ?

A

methacholine challenge
positive if >20% decrease in FEV1
sensitive but not specific

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6
Q

formoterol + ICS vs salmeterol + ICS

A

salmeterol + ICS = long acting LABA for maintenance
formoterol + ICS = MART maintenance and reliever therapy

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7
Q

ipratropium vs tiotropium

A

both muscarinic antagonists
ipratropium short acting SAMA
tiatropium long acting LAMA

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8
Q

mode of action of theophylline and potential side effects

A

inhibits phosphodiesterase - decreasing cAMP hydrolysis and cAMP levels = bronchodilatation
cardio and neurotoxic

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9
Q

mode of action and indication of cromolyn

A

inhibits release of vasoactive mediators from mast cells
useful in exercise induced bronchoconstriction
used for maintenance and not for acute attacks
toxicity is rare

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10
Q

action of zileon

A

5 lipoxygenase inhibitor - blocks conversion of arachidonic acid to leukotrienes

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11
Q

mode of action of mepolizumab vs benralizumab vs dubilumab

A

mepolizumab and benralizumab = IL-5 inhibitors

dubilumab = IL-4 inhibitor

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12
Q

features of bronchiectasis on high resolution CT

A

dilated airways and ballooned cysts at the end of the bronchus

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13
Q

abx of choice for exacerbation of bronchiectasis

A

flouroquinolone (levofloxacin or moxifloxacin)

or if sensitive to another abx on sputum culture

if allergic bronchopulmonary aspergillus is underlying cause of bronchiectasis then treat with antifungal + prednisolone

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14
Q

what part of the lung is mostly affected in COPD due to alpha 1 antitrypsin deficiency

A

base (basilar COPD)

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15
Q

what is proven to improve survival in COPD patients

A

smoking cessation
supplemental 02

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16
Q

DLCO in chronic bronchitis vs emphysema

A

diffusion capacity of lung for C0
decrease in emphysema but normal in chronic bronchitis

will be decreased in late-stage COPD
will be normal/increased in asthma

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17
Q

presentation of chronic bronchitis vs emphysema

A

chronic bornchitis - ‘blue bloater’. overweight, oedematous. ealry hypercarbia

emphysema - ‘pink puffer’, thin/wasted appearance, pursed lips, minimal cough, late hypercabia

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18
Q

next step in management of COPD exacerbation if not responding to medications and has altered mental status and worsening acid base balance

A

non-invasive positive pressure ventilation with BiPAP

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19
Q

indications for long term 02 therapy in COPD

A

Sp02 < 88 or Pa02 < 55mmHg

or
Spo02 < 89 or Pa02 < 59 with one of the following; cor pulmonale, polycythaemia (Htc 55%) or right heart failure

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20
Q

what vaccines are recommended for patients with COPD

A

once of pneumococcal and yearly influenza

19-64 years of age: PCV20 alone or PCV15+PPSV23
≥65 years of age: PCV20 alone or PCV15+PPSV23

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21
Q

describe the treatment algorithm for COPD

A

< 2 exacerbations per year;
- CAT < 10: SABA prn
- CAT > 10: SABA + LABA/LAMA

> 2 exacerbations per year;
- CAT < 10: SABA + LAMA
- CAT > 10: SABA + (LAMA +LAMA) or (LABA + ICS if asthma symptoms/IgE)

CAT = COPD assessment test

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22
Q

for determining management of COPD, how is severity determined

A

use of COPD assessment test to determine severity of symptoms

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23
Q

what is diffuse parenchymal lung disease

A

another name for interstitial lung disease

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24
Q

medications that can cause interstitial lung disease

A

amiodarone
bleomycin
methotrexate
busulfan
nitrofurantoin
radiation
long term 02 - ventillators

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25
best initial test for suspected interstitial lung disease
CXR (reticular, nodular or ground glass appearance)
26
most accurate test for diagnosing interstitial lung disease
surgical lung biopsy not recommended if CT scan findings are characteristic only performed if diagnosis is uncertain in rheumatoid induced or IPF
27
name x2 antifibrotic agents used in idiopathic pulmonary fibrosis (IPF)
nintenabid pirfenidone
28
what is cryptogenic organising pneumonia and how does it present
cryptogenic refers to its idiopathic nature organising refers to the localizing of granulation tissue at the distal airway spaces refers to an inflammatory process presents with subacute fever, dry cough, SOB, anorexia, failure to respond to antibiotics CXR: bilateral, peripheral patchy opacities that may migrate PFT: restrictive pattern biopsy is diagnostic treat with steroids
29
patient presents with low grade fever, SOB, cough and weight loss. Abx have been prescribed but show no improvement. CXR reveals patchy opacities bilaterally. ?diagnosis ?treatment
cryptogenic organziing pneumonia treat with steroids
30
extra-pulmonary manifestations of sarcoidosis
Eyes: uveitis Heart: 3rd degree heart block, arrythmia Liver CNS: cranial nerve defects Skin: erythema nodosum, violaceous skin papules MSK: migratory arthritis
31
best initial test for suspected sarcoidosis
CXR if CXR suspicious then will usually do high resolution CT chest
32
next best step if CXR/CT suspicious for sarcoidosis
bronchoscopic biopsy presence of non-caseating granulomas = diagnostic
33
lab findings in sarcoidosis
hypercalcaemia hypercalcinuria hypergammaglobulinaemia elevated alk phosph (liver involvement) lymphopenia
34
lofgrens syndrome and management
subtype of sarcoidosis that presents with bilateral hilar lymphadenopathy, migratory polyarthritis, erythema nodosum and fever treat with NSAIDS and supportive
35
complication associated with sillicosis
increased risk for TB
36
CXR shows small nodular opacitis in upper zones, egg shell calcifications
sillicosis
37
most common malignancy associated with asbestosis
bronchogenic carcinoma mesothelioma is rare
38
CXR shows linear opacities at lung bases and interstitial fibrosis with calcified plaques
asbestosis
39
presence of what in the sputum indicates asbestosis
ferrunginous bodies
40
history of working in aerospace or ceramic industry or dye manufacturing, CXR shows diffuse infiltrates and hilar adenopathy
berrylliosis
41
loffler syndrome
absent/mild respiratory symptoms high eosinophillic count in blood fleeting migratory pulmonary opacities
42
respiratory symptoms and sputum shows eosinophillic-rich plugs and charcot-layden crystals
allergic bronchopulmonary aspergillosis
43
underlying diseases associated with allergic bronchopulmonary aspgerillosis
asthma cystic fibrosis
44
how can CF and asthma management be optomized if they develop allergic bronchopulmonary aspergillosis
use of biologics i.e. omalizumab
45
best initial test for suspected allergic bronchopulmonary aspergillosis
Look for aspergillus sensitization; - aspergillus specific IgE antibodies - positive aspergillus skin prick test
46
in the diagnosis of allergic bronchopulmonary aspergillus, patient has positive aspergillus IgE antibodies. what is the next step?
check total serum IgE, eosinophil count, aspergillus preciptans sputum microscopy and culture CXR, CT
47
feature of sputum suggestive of allergic bronchopulmonary aspergillus
eosinophil plugs charcot-layden crystals
48
causes of respiratory failure with an increased A-a gradient (alveolar-arterial 02 gradient)
right to left shunt V/Q mismatch diffusion impairment
49
cause of respiratory failure with a normal A-a gradient
hypoventillation or low inspired 02
50
A-a graident normal, PaC02 elevated. ?caue of resp failure
hypoventillation; - obesity hypoventillation syndrome - cns depression - NMD - decreased respiratory drive
51
A-a graident normal, PaC02 normal. ?cause of rep failure
reduced inspired 02 (Fi02) i.e. high altitude
52
criteria for acute respiratory distress syndrome (ARDS) diagnosis
acute onset (<1 week) respiratory failure Pa02:Fi02 < 300 and PEEP / CPAP > 5cm h20 CXR features: bilateral alveolar opacities consistent with pulmonary oedema respiratory failure not explaIned by heart failure
53
indications for prone position in treating ARDS
Pa02/Fi02 < 150 Fi02 >6 PEEP > 5cm h20
54
in the management of ARDS, how can the risk of lung injury induced by mechanical ventillation be reduced
use of low tidal volumes (6 xx per kg body weight) to prevent ventillator induced lung injury by over distending the alveoli
55
criteria for extubation after a patient has been treated with mechanical ventillation for ARDS
the cause of respiratory failure has improved ventillator support required is minimal oxygen supplementation is easily accomplished without the use of PEEP patient passess a spontaneous breathing trial
56
PEEP is beneficial for left or right heart failure?
PEEP is beneficial for left heart failure as increased intrathoracic pressure causes decrease in preload and afterload
57
complications associated with mechanical ventillation
volutrauma - excessive vol barotrauma - excessive pressure atelectrauma - repetitive opening and closing of alveoli biotrauma - inflammatory mediators oxygen effect - high Fi02 causing famage tension pneumothorax
58
how is barotrauma, volutrauma, atelectrauma and oxygen trauma minimised with mechanical ventillation
barotrauma minimised with pressure set at <30mmHg volutrauma minimised by using lower tidal volumes atelectrauma minimised with using PEEP oxygen effect injury minimised by aiming for Fi02 < 0.6
59
patient on mechanical ventillation suddenly develops acute hypotension with increase in peak inspiratory pressure ?diagnosis ?next step
tension pneumothroax complication of mechanical ventillation next step is CXR to confirm
60
x3 causes of hypotension in a patient on mechanicam ventillation
tension pneumothorax increased PEEP increases intrathoracic pressure which can decrease venous return and therefore decrease output = low BP sedatives and opiates can lower BP
61
most common lab result found in COVID
lymphopenia
62
lab results found in COVID infection
lymphopenia thrombocytopenia elevated AST and ALT elevated LDH elevated creatinine elevated d-dimer elevated CRP
63
most sensitive diagnostic test for COVID infection
NAAT, also known as reverse transcriptase-PCR (RT-PCR) of nasopharyngeal aspirate
64
mean pulmonary arterial pressure suggestive of PAH
> 20mmHg
65
features of pulmonary HTN on examination
loud, palpable S2 flow murmur S4 parasternal heave elevated JVP, oedema, abdo distension
66
best initial test for suspected PAH / cor pulmonale
ECHO that estimates pulmonary arterial pressure and right ventricular functioning
67
investigation of choice for diagnosing pulmonary arterial hypertension
right heart catheterization
68
feature on CXR suggesting raised pulmonary arterial pressure
enlarged central pulmonary artery with rapid tapering of distal vessels (pruning)
69
medication options for management of primary pulmonary arterial hypertension (group 1)
prostanoids e.g. beraprost endothelin receptor antagonists i.e. ambrisentan PDE inhibitors i.e. sildenafil some patients have vasoreactivity and respond well to CCB
70
features of the wells criteria
signs/symptoms of DVT - 3 DVT/PE most likely diagnosis - 3 immobility for 3 or more days or surgery in last month - 1.5 tachycardia - 1.5 previous DVT/PE - 1.5 malignancy - 1 haemoptysis - 1 4 or less = D-dimer 5 or more = CTPA
71
treatment for confirmed PE if anticoagulants is contraindicated
IVC filter CI include: recent haemorrhagic stroke, active bleeding, recent surgery or aortic dissection
72
lung nodule in patient from southwestern region of US
coccidiodomycosis
73
lung nodule in immigrant
TB
74
lung nodule in patient from ohio river valley
histoplasmosis or blastomyces
75
CT shows lung nodule of 1cm. previous CT shows this was present 2 years previous and hasnt changed in size. ?next step
if nodule is old, <2 cm and non-changing from previous scan then no further work up necessary
76
what are high-risk features of a lung nodule
diameter >20mm patient age >60 yrs smoking history if pt stopped smoking its less than 5 yrs nodule - corona radiata or spiculated absent or irregular calcifications
77
if patient has intermediate risk for malignancy with lung nodule of 9cm, next step?
low/intermediate malignancy risk --> assess nodule size if < 4mm and low risk: no further evaluation if < 4mm and intermediate risk: serial CT scans if 5-7mm: serial CT scans if >8mm: PET or biopsy
78
40 yr old patient has a lung nodule found on CXR that is 3mm. never smoked. nodule is smooth with calcifications. ?next step
risk is low due to age (<45), nodule is < 8mm, never smoked, smooth and presence of calcifications low risk with size < 4mm = no further evaluation if he had an intermediate risk i.e. was 60 years old, then would require serial CT scans (REFER TO PAGE 647 IN FIRST AID FOR FLOW DIAGRAM)
79
70 year old smoker is found to have an 8mm lung nodule. ?next step
patient has intermiedate risk (age, smoker, size of nodule) for malignancy. his nodule is >8mm so requires PET or biopsy as the next step.
80
metastatic locations of lung cancer
lung cancer found in LABB's liver adrenals bone brain
81
lung cancer chromogranin A positive
small cell lung cancer - neoplasm of neuroendocrine kulchistky cells --> small, dark blue cells bronchial carcinoid tumour - nests of neuroendocrine cells
82
lung cancer associated with hypercalcaemia
squamous cell lung cancer (PTHrP)
83
lung cancer that stains positive for mucin
adenocarcinoma - glandular pattern on histology - bronchoalveolar subtype shows thickening of alveolar walls
84
most accurate test for diagnosing lung cancer
bronchoscopy (biopsy or brushing) for central lesions i.e. SCLC, squamous fine needle aspiration (CT guided) for peripheral lesions i.e. NSCLC
85
what type of lung cancer is associated with KRAS, EGFR and ALK translocation
adenocarcinoma
86
when is flu vaccination recommended
all patients 6 months and older are recommended to get the annual influenza vaccine patients 6months-8yrs receive x2 doses if its their first time receiving the vaccinations those >65yrs, co-morbidities +/- immunocompromised can receive a higher dose vaccine
87
best initial test for influenza
rapid influenza test for viral antigens from nasopharyngeal swab
88
most accurate test for influenza
PCR, viral culture or direct fluorescent antibody test (DFA)
89
when is oseltemavir most useful in influenza
if taken within 2 days of symptom onset
90
histoplasmosis risk factors, presentation, diagnostic investigation
Ohio-missisippi river valley, bats caves presentation can range from asymptomatic to dry cough, fever, SOB disseminated infection: lymphadenopathy, hepatomgaly diagnosis: urine and serum polysacharide assay
91
management of histoplasmosis
mild: supportive, consider itraconazole chronic: itraconazole acute severe or disseminated disease: amphotericin B for 14 days followed by itraconazole for 1 year
92
coccidiodomycosis risk factors, presentation and diagnosis
southwestern states of US pregnant, HIV, filipino/african descent increased risk of disseminated disease range from asymptomatic to severe flu like illness with disseminated infection involving bone, CNS (meningitis), erythema multiforme, soft tissue abscesses PCR of bronchoalveolar lavage positive complement fixation test
93
treatment for coccidoidomycosis, blastomyces and histoplasmosis
treatment is similar with the following basic principles; acute mild: oral itraconazole or fluconazole acute severe: IV amphotericin B chronic: prolonged courses of itraconazole, but if asymptomatic then no treatment (only in blastomyces)
94
blastomycoses risk factors, presentation and diagnosis
ohio and mississippi river valleys presents similar to coccidioidomycoses disseminated infection affecting CNS, prostate and skin diagnosis with culture (broad based budding yeast)
95

Respiratory (5 decks)

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