Resp

Question 1

causes of new onset AF

Answer 1

SMITH + AC
S – Sepsis
M – Mitral valve pathology (stenosis or regurgitation)
I – Ischaemic heart disease
T – Thyrotoxicosis
H – Hypertension

Alcohol and caffeine are lifestyle causes worth remembering

Question 2

What is paroxysmal AF, Ix and how is it managed

Answer 2

Paroxysmal atrial fibrillation refers to episodes of atrial fibrillation that reoccur and spontaneously resolve back to sinus rhythm. These episodes can last between 30 seconds and 48 hours.

Patients with a normal ECG and suspected paroxysmal atrial fibrillation can have further investigations with:

24-hour ambulatory ECG (Holter monitor)
Cardiac event recorder lasting 1-2 weeks

Mx:

• pill inpocket flecainide
• catheter ablation
• DOAC if indicated

Question 3

COPD Mx

Answer 3

General management:

• > smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
• annual influenza vaccination
• one-off pneumococcal vaccination
• pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)

Question 4

how is inhaler Mx chosen in COPD

Answer 4

dependent on asthmatic features

Question 5

how is COPD severity determined

Answer 5

Using FEV1: 30-50-80
(Post bronchodilator fev1)

Question 6

obstructive sleep apnoea Ix and Mx

Answer 6

Ix:

• epworth sleepiness scale score to assess symptoms of sleepiness associated with OSA.
• sleep studies done by ENT

Mx:

• Reversible risk factors should be addressed, with reduced alcohol, smoking cessation and weight loss.
• Continuous positive airway pressure (CPAP) machines provide constant pressure to maintain airway patency.
• Surgery is an option but involves significant surgical reconstruction of the soft palate and jaw. The most common procedure is called uvulopalatopharyngoplasty (UPPP).

Question 7

which organisms cause cavitating pneumonia

Answer 7

• Staphylococcus aureus (especially MRSA): Causes necrotising pneumonia with abscess and cavity formation.
• Klebsiella pneumoniae: Particularly in alcoholics and immunocompromised patients; leads to necrosis and cavitation.
• Pseudomonas aeruginosa: Seen in hospital-acquired infections, especially in cystic fibrosis or ventilated patients.
• Mycobacterium tuberculosis: Classic cause of cavitary lesions in the upper lobes

Question 8

features of mycoplasma pneumonia

Answer 8

• the disease typically has a prolonged and gradual onset
• flu-like symptoms classically precede a dry cough
• bilateral consolidation on x-ray
• complications may occur as below

complications
- erythema multiforme
- GBS
- meningoencephalitis
- haemolytic anaemia or ITP
- pericarditis or myocarditis

Question 9

horner’s syndrome =

Answer 9

• ptosis
• miosis
• anhydrosis
• resulting from interrupted sympathetic nerve supply to the eye

Question 10

when would you refer an asthma pt to specialist

Answer 10

refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART and

• trials of an LTRA and a LAMA unsuccesful
  OR
• raised blood eisinophils +/or FENO

Question 11

Criteria for life-threatening asthma:

Answer 11

33 92 CHEST

33 - PEFR < 33%

92 - Oxygen sats < 92%

C - cyanosis/ confusion

H - hypotension

E - exhaustion (normal pCO2)

S - silent chest

T - tachycardia / bradycardia

Question 12

pulmonary fibrosis:

1. • what is it
2. • CFs
3. • Ix/Dx
4. • Mx

Answer 12

1. Inflammation and and fibrosis of the lung parenchyma i.e. replacement of functional elastic lung tissue with non-functional scar tissue –> restrictive lung pattern
2. -SoB on exertion
   -Dry cough
   -Fatigue
   -clubbing
   -On examination: Bibasal fine end-inspiratory crackles + Finger clubbing
3. -Clinical features
   -High resolution CT – ground glass appearance in early stages => honeycombing later
   -Spirometry – restrictive pattern
   -lung biopsy / bronchalveolar lavage
4. Meds to slow progression by ↓ fibrosis and inflammation: Pirfenidone + Nintedanib – tyrosine kinase inhibitor
   -oxygen + palliative care

Question 13

pleural plaques suggest

Answer 13

asbestos exposure
Pleural plaques are benign and do not undergo malignant change

Question 14

A normal PaCO2 in an acute asthma suggests…

Answer 14

attack indicates exhaustion and should, therefore, be classified as life-threatening

Question 15

The most common organism causing infective exacerbations of COPD is

Answer 15

Haemophilus influenzae = MC
also: Streptococcus pneumoniae + Moraxella catarrhalis

Question 16

The most common organism causing infective exacerbations of bronchiectasis is

Answer 16

Haemophilus influenzae = MC
also: Streptococcus pneumoniae + Pseudomonas aeruginosa + Klebsiella spp.

Question 17

conservative care of pneumothorax

Answer 17

Indications:

• Primary spontaneous pneumothorax <2 cm rim of air on chest X-ray
• Patient clinically stable with no breathlessness or minimal symptoms
• No underlying lung disease or secondary causes

Mx:

• patients with a primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient
• patients with a secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient
• if stable, follow-up in the outpatients department in 2-4 weeks

Question 18

pneumonia severity assessment tool

Answer 18

• CRB-65 in primary care
  
  • 0= treat as outpatient
  • 1-2 = consider hospital treatment
  • ≥3= urgent hospital admission.
• CURB 65 in secondary care
  
  • 0-1 = low risk
  • 2 = intermediate risk
  • ≥3 = high risk may need ICU

Question 19

CPAP Vs BiPAP
which is used for COPD

Answer 19

• CPAP delivers one pressure setting and, as such, will aid with oxygenation rather than ventilation. It is a useful tool in chronic heart failure or sleep apnoea to increase oxygen saturations and increase intrathoracic pressure
• BiPAP s set at two different pressures (one for inhalation and one for exhalation). This is a useful tool for patients who require assistance with ventilation [T2RF pts]
• BiPAP used for COPD

Question 20

how to calculate pack years

Answer 20

(Cigarettes per day / 20) × Years smoked = Pack Years

Question 21

bronchiectasis
1. what is it
2. CFs
3. Ix/ Dx
4. Mx

Answer 21

1. irreversible dilatation of the airways, often as a result of chronic infection or inflammation
2. -SoB
   -Recurrent chest infection
   -Chronic productive cough
   -Weight loss
   -Haemoptysis
   -Dyspnoea
   -clubbing
   -Scattered crackles throughout the chest that change or clear with coughing
   -Scattered wheezes and squeaks
3. -Xray: Tram-track opacities (parallel markings of a side-view of the dilated airway) + Ring shadows (dilated airways seen end-on)
   -high resolution CT = diagnostic imaging
4. ciprofloxacin for psuedomonas infection
   -vaccinations
   -lung rehab/ physio
   -bronchodilators
   -oxygen therapy
   -surgical lung resection or transplant

Question 22

high risk characteristics in pneumothorax pts

Answer 22

• haemodynamic compromise (suggesting a tension pneumothorax)
• significant hypoxia
• bilateral pneumothorax
• underlying lung disease
• ≥ 50 years of age with significant smoking history
• haemothorax

Question 23

summarise asthma Mx

Answer 23

Step 1

• a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief
  
  • this is termed anti-inflammatory reliever (AIR) therapy
• if the patient presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation:
  
  • start treatment with low-dose MART (maintenance and reliever therapy, see below)
  • treat the acute symptoms as appropriate (e.g. a course of oral corticosteroids may be indicated)

Step 2

• a low-dose MART
  
  • inhaled corticosteroid (ICS)/formoterol combination inhaler

Step 3

• a moderate-dose MART

Step 4

• check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count NICE
  
  • if either of these is raised, refer to a specialist in asthma care
• if neither FeNO nor eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART
  
  • if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)

Step 5

• refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA

Question 24

acute asthma attack Mx - SIGN guidelines

Answer 24

Oh Shit I Hate My Asthma
Oh
Shit,
I
Hate
My
Asthma

1) Oxygen
2) Salbutamol nebulisers
3) Ipratropium bromide nebulisers
4) Hydrocortisone IV or Oral Prednisolone
5) Magnesium Sulfate IV
6) Aminophylline / IV salbutamol
7) Escalate / intubate + ventilate.

Question 25

Criteria for discharge following acute asthma attack

Answer 25

* been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours * inhaler technique checked and recorded * PEF >75% of best or predicted

Question 26

types of paraneoplastic syndromes

Answer 26

SCLC: * SIADH --> dilutational hyponatraemia * Cushing's syndrome caused by ectopic ACTH * Lambert-Eaton myasthenic syndrome * Proximal muscle weakness caused by antibodies against voltage gated calcium channels. * Limbic encephalitis: SCLC causes the immune system to create anti-Hu antibodies to limbic brain tissue =>memory loss, hallucinations, confusion + seizures. NSCLC: * Hypercalcaemia caused by SCC production of PTH-related protein => bony mets. * Gynaecomastia: caused by ectopic hcg => ↑ LH => ↑ testosterone which is converted to oestrogen. Associated with adenocarcinoma.

Question 27

Bronchiectasis: most common organism =

Answer 27

Haemophilus influenzae

Question 28

define bronchiectasis

Answer 28

Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation

Question 29

Idiopathic pulmonary fibrosis predominantly affects what location

Answer 29

the lower zones of the lungs

Question 30

asthma attack severities

Answer 30

A fourth category, 'Near-fatal asthma', is also recognised characterised by a raised pCO2 and/or requiring mechanical ventilation with raised inflation pressures.

Question 31

abx options for IECOPD

Answer 31

* amoxicillin * doxycycline * clarithromycin

Question 32

define hospital acquired pneumonia + its Tx

Answer 32

Pneumonia that occurs ≥ 48 hours after admission is defined as a hospital-acquired pneumonia Tx = Tazocin - Piperacillin-tazobactam

Question 33

classical findings for pneumonia caused by Mycoplasma pneumoniae - diagnostic test

Answer 33

* erythema multiforme * bilateral consolidation on chest x-ray /// - mycoplasma serology

Question 34

pleural effusion - exudate - classification - causes

Answer 34

* >30g/l = exudate

Question 35

pleural effusion - transudate - classification - causes

Answer 35

* <30g/l = transudate