Sub-Acute Breathlessness

Question 1

Name three common bacterium which cause respiratory disease.

Answer 1

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis

Question 2

Name two common fungi which cause respiratory disease.

Answer 2

Aspergillus fumigatus
Pneumocystis jiroveci

Question 3

What Gram-stain class are all streptococcus bacteria?

Answer 3

Gram positive cocci

Question 4

What Gram-stain class is Clostridium difficile?

Answer 4

Gram positive bacilli

Question 5

What investigations can be conducted to confirm an adult asthma diagnosis? (4)

Answer 5

Peak flow and peak flow diary, spirometry and exhaled nitric oxide (FeNO).

Question 6

What are the four main types of inhaler medications?

Answer 6

Short acting bronchodilator (SABA)
Long acting bronchodilator (LABA)
Inhaled corticosteroid
LABA/ICS

Question 7

What is the mode of action of inhalers with the suffix -one?

Answer 7

Inhaled corticosteroid (ICS)

Question 8

What is the mode of action of salbutamol?

Answer 8

Short acting bronchodilator (SABA)

Question 9

How should inhalers be prescribed to ensure patients get the correct type?

Answer 9

Approved name followed by the brand name, except salbutamol which is usually approved drug name followed by type of inhaler.

Question 10

How should you advise patients to use each of the two main types of inhaler devices?

Answer 10

Metered dose inhalers (MDIs) - inhale slow and steady.
Dry powdered inhalers (DPIs) - inhale quick and deep.

Question 11

What pH values indicate alkalosis and acidosis respectively?

Answer 11

High pH (pH>7.45) indicates alkalosis.
Low pH (pH<7.35) indicates acidosis.

Question 12

What is fruity smelling breath indicative of in clinical practice?

Answer 12

Serious ketosis/ketoacidosis (due to exhalation of acetone).

Question 13

What blood gas results would indicate respiratory acidosis?

Answer 13

Increased PCO2 (and increased HCO3- in cases of chronic disease).

Question 14

What blood gas results would indicate respiratory alkalosis?

Answer 14

Decreased PCO2 (and decreased HCO3- in cases of chronic illness).

Question 15

What is metabolic acidosis?

Answer 15

A process leading to reduced bicarbonate conc in blood due to either increased H+ production or decreased excretion/loss of HCO3-.

Question 16

What is respiratory acidosis?

Answer 16

Condition characterised by CO2 retention; may be due to primary lung pathology as well as respiratory centre/muscle diseases or upper airway obstruction.

Question 17

What is metabolic alkalosis?

Answer 17

A process leading to increased HCO3- in blood due to either excess alkali intake, loss of gastric acid (during vomiting) or potassium depletion.

Question 18

What is respiratory alkalosis?

Answer 18

Condition characterised by fall in pCO2 as result of hyperventilation (mechanical/hysterical overbreathing) or stimulation of respiratory centre.

Question 19

What are the six stages of interpreting blood gas results?

Answer 19

1. Look at pH
2. Look at metabolic component (HCO3)
3. Look at respiratory component (pCO2)
4. Combine all above info.
5. Check compensation if appropriate.
6. Look at pO2 level.

Question 20

What is the difference between the FEV1/FVC ratio in obstructive and restrictive lung disease?

Answer 20

Obstructive - ratio decreased below 70%.
Restrictive - ratio is 70% or above (normal or increased) because FVC and FEV1 both decrease a similar amount.

Question 21

What three important questions should be asked at an annual asthma review?

Answer 21

• In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms, shortness of breath)?
• Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?
• Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?

Question 22

How often should peak expiratory flow rate (PEFR) be recorded during peak flow investigation for an asthma diagnosis?

Answer 22

2-4 weeks, twice daily (NICE 2017).

Question 23

What is the alveolar-arterial (A-a) gradient?

Answer 23

The gap between the alveolar oxygen (oxygen being breathed in) and arterial oxygen (amount of oxygen in the blood) - usually expected to be around 10kPa.

Question 24

What A-a gradient would indicate a lung problem?

Answer 24

A gradient of much greater than 10 (unless O2 level being breathed in is greater than 50%).

Question 25

What finding in a full blood count indicates bacterial pneumonia?

Answer 25

Neutrophilia.

Question 26

What finding in a full blood count indicates influenza or covid?

Answer 26

Lymphopenia.

Question 27

What is elevated lactate indicative of?

Answer 27

Sepsis.

Question 28

What are the four common features of pneumonia?

Answer 28

Cough (dry or productive)
Breathlessness
Fever
Chest pains (commonly pleuritic, worse on coughing)

Question 29

What colour is sputum characteristically in pneumococcal pneumonia?

Answer 29

Rust/red coloured - haemoptysis can also occur.

Question 30

What signs of pneumonia can be heard on auscultation?

Answer 30

Crepitations or bronchial breathing over the affected area - sometimes accompanied by a pleural rub.

Question 31

What can neutropenia indicate?

Answer 31

Viral infections.

Question 32

What is the pathophysiological explanation of bacterial pneumonia?

Answer 32

Bacterial pneumonia is characterised by acute inflammation of the lung parenchyma.

Question 33

What four microbes are ‘typical’ causes of community acquired bacterial pneumonia?

Answer 33

Streptococcus pneumoniae
Haemophilus influenzae
Klebsiella pneumoniae
Staphylococcus aureus

Question 34

What is meant by typical and atypical pneumonia?

Answer 34

Typical pneumonia is caused by organisms that can be cultured in the lab, whereas atypical organisms are intracellular pathogens and cannot be cultured using standard methods.

Atypical organisms need to be treated with antibiotics that can get into intracellular space, and do not possess a cell wall on which penicillins or cephalosporins can act.

Question 35

What antibiotics are given for low severity community acquired pneumonia?

Answer 35

Amoxicillin (or alternatively doxycycline or clarithromycin).

Question 36

What antibiotics are given for moderate severity community acquired pneumonia?

Answer 36

Amoxicillin and a macrolide.

Question 37

What antibiotics are given for severe community acquired pneumonia?

Answer 37

A broad spectrum beta-lactamase stable antibiotic such as co-amoxiclav together with a macrolide.

Question 38

What is empyema?

Answer 38

Pus in the pleural space.

Question 39

What is a lung abscess?

Answer 39

Pus in a non-preformed space of the lung.

Question 40

What common organisms should be considered when dealing with a hospital acquired pneumonia? (3)

Answer 40

Staphylococci (including MRSA)
Enterococci
Gram negative bacilli (or a mixed flora if aspiration pneumonia suspected)

Question 41

Which lobe of the lung is most often involved with aspiration pneumonia?

Answer 41

The right lower lobe - due to this being the straightest path from the trachea through the bronchi.

Question 42

Define hospital acquired pneumonia (HAP).

Answer 42

A new onset of symptoms along with a compatible x-ray developing more than 48 hours after the patient’s admission to hospital.

Early onset HAP: occurs within 4-5 days of admission.
Late onset HAP: occurs after at least 6 days of admission.

Question 43

How can you distinguish between an effusion and consolidation radiologically?

Answer 43

Consolidation - margins of opacification are not clear compared to effusions; diaphragm/costophrenic and cardiophrenic angles may still be visible depending on which areas of lungs are affected. Visible air bronchograms, so opacification not as dense.

Effusions - dense opacification with clearer margins and no visible lung markings; diaphragm/costophrenic and cardiophrenic angles are not visible.