resp important

Question 1

COPD spirometry

Answer 1

FEV1/FVC ratio less than 70%, FEV1 less than 80%

Question 2

treatment COPD

Answer 2

1- SABA/SAMA
2- no asthmatic features: add LABA + LAMA (if taking SAMA, switch it to SABA)
3- asthmatic features: add LABA + ICS, if patients remain breathless then add LAMA also

Question 3

first line antibiotics for infectious exacerbation of COPD

Answer 3

amoxicillin or clarithromycin or doxycycline

Question 4

Most frequent cause of COPD exacerbation

Answer 4

haemophilus influenzae

Question 5

COPD symptoms in a young person may be a sign of

Answer 5

A1AT deficiency

Question 6

how to tell severity of COPD

Answer 6

mild COPD- normal FEV1
moderate COPD- FEV1 50-70%
severe COPD- FEV1 30-49%
very severe FEV1<30%

Question 7

clinical features Wegener’s granulomatosis

Answer 7

• saddle nose/sinus pain/epistaxis
• airway constriction- difficulty breathing, cough
• kidney problems- reduced urine production, increased blood pressure, haematuria/proteinuria
• skin purpura/nodules

Question 8

tests for Wegener’s granulomatosis

Answer 8

• cANA- IgG antibody
• increased ESR + CRP
• CXR- fluffy infiltrates or nodules

Question 9

treatment Wegener’s granulomatosis

Answer 9

• corticosteroids + cyclophosphamide (or rituximab) for disease remission
• Azathioprine and methotrexate for maintenace
• plasma exchange if severe renal disease & pulmonary haemorrhage
• Co-trimoxazole - prophylaxis against pneumocystis jirovecii and staph colonisation

Question 10

small cell cancer features

Answer 10

Paraneoplastic syndrome- ACTH, ADH and also can create autoantibodies that destroy neurones, causing lambert-eaton syndrome

Question 11

adenocarcinoma features

Answer 11

• can cause pancoast tumours in upper nerve
• can damage thoracic inlet, brachial plexus and cervical sympathetic nerve; Horner’s syndrome (constricted pupil, drooping upper eyelid and cant sweat on same side as nerve damage)
• Often see triad of clubbing, long bone swelling and arthritis

Question 12

squamous cell carcinoma features

Answer 12

• Form square shaped cells that produce keratin pearls
• Centrally located
• Paraneoplastic syndrome possible- parathyroid hormone release, which decreases calcium in bones - leads to hypercalcaemia (more calcium in blood) and bones are more brittle

Question 13

Bronchial carcinoid tumour features

Answer 13

• Develop from mature endocrine cells
• Can be located throughout the lungs
• Paraneoplastic syndrome- tumours release serotonin which causes increased peristalsis of gut, diarrhoea, and bronchoconstriction which causes asthma

Question 14

lung cancer associated with gynaecomastia

Answer 14

adenocarcinoma

Question 15

cancer with strongest associated with smoking

Answer 15

squamous cell carcinoma

Question 16

stats for moderate asthma

Answer 16

PEFR 50-75% best of predicted
RR<25/min
pulse <110

Question 17

stats for severe asthma

Answer 17

PEFR 33-50% best of predicted
cannot complete sentences
RR >25/min
Pulse >110

Question 18

stats for life-threatening asthma

Answer 18

PEFR <33% best or predicted 
Oxygen sats <92% 
'normal' pCO2 
silent chest, cyanosis, feeble respiratory effect 
confusion or soma 
hypotension or bradycardia

Question 19

acute asthma attack management

Answer 19

1- oxygen 
2- salbutamol 
3- ipratropium bromide nebuliser 
4- IV hydrocortisone or oral Prednisolone 
5- magnesium sulfate IV

Question 20

investigations for asthma

Answer 20

• FEV1/FVC <70% (obstructive)
• peak flow- variability of more than 20% between am and pm measurements
• fractional exhaled nitric oxide + bronchodilator reversibility test if the spirometry comes back normal despite symptoms

Question 21

asthma management in adults

Answer 21

1- SABA 
2- SABA + ICS 
3-  SABA + ICS + LABAS
4-ABA + ICS + LTRA (e.g. montelukast) 
5- SABA + LTRA + MART

Question 22

types of hypersensitivity

Answer 22

ACID
1- Allergy (immediate)- IgE
2- Cytotoxic- antibody dependent- IgM/IgG e.g. Goodpasture’s
3- Immune complex- IgG + neutrophils e.g. SLE, pneuomonitis, Wegener’s
4- Delayed hypersensitivity- cell mediated by T cells- e.g. Tuberculosis =, nickel, poison IV

Question 23

o Kidney biopsy: inflammation in the basement membrane- ‘crescent glomerulonephritis’
AND
CXR shows infiltrates due to pulmonary haemorrhage

Answer 23

Goodpasture’s syndrome (anti-glomerular basement membrane disease, a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs and kidney failure.)

Question 24

diagnostic test for severity of Pneumonia + use of score

Answer 24

Confusion- 1 point 
Urea >7mmol/L - 1 point 
RR >30 - 1 point 
B: SBP<90 OR DBP <60- 1 
65- age over 65 

score of 0-1= home treatment, 2=admission/close outpatient management, 3-5= admission as severe

Question 25

pneumonia antibiotics

Answer 25

 Strep pneumoniae / H. influenzae / mycoplasma pneumoniae = amoxicillin, clarithromycin or doxycycline  Legionella pneumophilia = fluroquinolone  Chlamoydophila species = tetracycline  Pneumocystis jiroveci = co-trimoxazole  Gram -ve bacilli / pseudomonas / anaerobes = aminoglycoside IV + antipseudomonal penicillin IV  Strep pneumoniae / anaerobes from aspiration = cephalosporin IV + metronidazole

Question 26

most common organisms causing; 1- community acquired pneumonia 2- hospital acquired pneumonia

Answer 26

1- strep pneumoniae most common, but can also be caused by haemophilus influenzae or Moraxella 2- hospital acquired usually caused by staph aureus but may also be caused by pseudomonas, bacteriodes, clostridia

Question 27

cell wall can hold onto dye despite being exposed to alcohol, which creates a bright red colour with a Ziehl-Neelson stain

Answer 27

mycobacterium tuberculosis

Question 28

sarcoidosis signs/symptoms

Answer 28

- bilateral hilar lymphadenopathy - fever - erythema nodosum (swollen subcutaneous fat under ski, causing red bumps and patches) - polyarthralgia - uveitis- can cause vision changes

Question 29

bilateral hilar lymphadenopathy

Answer 29

sarcoidosis

Question 30

Facial rash plus lymphadenopathy

Answer 30

sarcoidosis

Question 31

drugs which can cause pulmonary fibrosis

Answer 31

* Methotrexate * Nitrofurantoin * Amiodarone * Sulphasalazine * Bleoycin

Question 32

features pleural effusion

Answer 32

dyspnoea, non-productive cough or chest pain are possible presenting symptoms classic examination findings include dullness to percussion, reduced breath sounds and reduced chest expansion

Question 33

Pleural effusion: causes

Answer 33

Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration. Transudate (< 30g/L protein) heart failure (most common transudate cause) hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption) hypothyroidism Meigs' syndrome ``` Exudate (> 30g/L protein) infection: pneumonia (most common exudate cause), TB, subphrenic abscess connective tissue disease: RA, SLE neoplasia: lung cancer, mesothelioma, metastases pancreatitis pulmonary embolism Dressler's syndrome yellow nail syndrome ```

Question 34

pleural effusion investigations

Answer 34

- PA CXR - ultrasound- increases the likelihood of successful pleural aspiration and is sensitive for detecting pleural fluid septations; contrast CT is now also increasingly performed to investigate the underlying cause, particularly for exudative effusions - PLEURAL ASPIRATION

Question 35

management pleural effusion

Answer 35

Options for managing patients with recurrent pleural effusions include: recurrent aspiration pleurodesis indwelling pleural catheter drug management to alleviate symptoms e.g. opioids to relieve dyspnoea

Question 36

pneumothorax features

Answer 36

``` dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia ```

Question 37

management pneumothorax

Answer 37

- first line aspiration | - if aspiration fails, insert chest drain

Question 38

PE management

Answer 38

- large clots and haemodynamically unstable= alteplase 10mg over 1 min then 90mg over 2 hours - haemodynamically stable= LMWH then start oral anticoagulant

Question 39

pink puffers and blue bloaters

Answer 39

differentiation in COPD: pink puffer= emphysema: high alveolar ventilation, near normal partial pressure of O2, normal or low partial pressure of CO2, breathless but not cyanosed, can progress to type 1 respiratory failure blue bloater= chronic bronchitis: have low alveolar ventilation, low partial pressure of O2, high partial pressure of CO2, cyanosed but not breathless, may develop cor pulmonale, their respiratory centres are insensitive to CO2 and they require a hypoxic drive to maintain respiratory effort (be careful when giving supplementary oxygen)

Question 40

type I resp failure + causes

Answer 40

hypoxia (PaO2<8kPa) with normal or low pCO2 caused by ventilation /perfusion mismatch e.g. pneumonia, pulmonary oedema, PE, asthma, emphysema, pulmonary fibrosis, acute respiratory distress syndrome

Question 41

type II resp failure + causes

Answer 41

hypoxia (PaO2<8kPa) with hypercapnia (PaCO2>6kPa) caused by: - pulmonary disease e.f. asthma, COPD, pneumonia, end stage pulmonary fibrosis, obstructive sleep apnoea - reduced respiratory drive- sedative drugs, CNS tumour, trauma - neuromuscular disease- cervical cord lesion, diaphragmatic paralysis, poliomyelitis, myasthenia gravis, guillan-barre syndrome - thoracic wall disease- flail test, hyphoscoliosis