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Respiratory Flashcards

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1
Q

signs of superior vena cava syndrome

A

SOB
face swelling
headache
pembertons positive (worsen with raising arms)

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2
Q

Upper zone fibrosis and egg shell calcification

A

Silicosis

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3
Q

What is the most important general management step in stable COPD?

A

Smoking cessation, including offering NRT, varenicline, or bupropion.

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4
Q

What vaccinations are recommended in stable COPD management?

A

Annual influenza and one-off pneumococcal vaccination.

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5
Q

Who should be offered pulmonary rehabilitation in COPD?

A

Patients who view themselves as functionally disabled, usually MRC grade 3 or above.

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6
Q

What is the first-line bronchodilator therapy in COPD?

A

A short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA).

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7
Q

What criteria suggest asthmatic or steroid responsiveness in COPD?

A

Previous asthma or atopy, high eosinophil count, FEV1 variation ≥400 ml, peak flow variation ≥20%.

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8
Q

What does NICE say about spirometric reversibility testing in COPD?

A

It is not routinely recommended as it may be unhelpful or misleading.

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9
Q

What treatment is recommended for COPD patients without steroid responsiveness?

A

LABA + LAMA; stop SAMA and use SABA if needed.

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10
Q

What treatment is recommended for COPD patients with steroid responsiveness?

A

LABA + ICS, progressing to triple therapy (LAMA + LABA + ICS) if needed.

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11
Q

When is oral theophylline recommended in COPD?

A

After trials of inhaled therapies or if inhaled therapy cannot be used.

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12
Q

How should theophylline dosing be adjusted with macrolides or fluoroquinolones?

A

Reduce the dose.

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13
Q

When is azithromycin prophylaxis recommended in COPD?

A

In non-smoking patients with optimized therapy and ongoing exacerbations after CT, sputum culture, LFTs, and ECG.

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14
Q

What standby medications does NICE recommend for certain COPD patients?

A

Oral corticosteroids and antibiotics for home use in those with recent exacerbations and understanding of use.

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15
Q

When should mucolytics be considered in COPD?

A

In patients with a chronic productive cough, and continued if symptoms improve.

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16
Q

Who should receive PDE-4 inhibitors (e.g., roflumilast) in COPD?

A

Patients with FEV1 <50% and ≥2 exacerbations in past year despite triple therapy.

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17
Q

What are signs of cor pulmonale in COPD?

A

Peripheral oedema, raised JVP, parasternal heave, loud P2.

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18
Q

How is cor pulmonale managed in COPD?

A

Loop diuretics for oedema; consider long-term oxygen therapy. Avoid ACE inhibitors, CCBs, and alpha blockers.

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19
Q

What interventions improve survival in stable COPD?

A

Smoking cessation, long-term oxygen therapy (if indicated), and lung volume reduction surgery (in selected patients).

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20
Q

What are the predisposing factors for obstructive sleep apnoea/hypopnoea syndrome?

A

Obesity, macroglossia (acromegaly, hypothyroidism, amyloidosis), large tonsils, Marfan’s syndrome

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21
Q

What symptoms might a partner report in obstructive sleep apnoea/hypopnoea syndrome?

A

Excessive snoring and periods of apnoea

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22
Q

What are the consequences of obstructive sleep apnoea/hypopnoea syndrome?

A

Daytime somnolence, compensated respiratory acidosis, hypertension

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23
Q

What tools are used to assess sleepiness in sleep apnoea?

A

Epworth Sleepiness Scale and Multiple Sleep Latency Test (MSLT)

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24
Q

What does the Multiple Sleep Latency Test (MSLT) measure?

A

The time to fall asleep in a dark room using EEG criteria

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25
What diagnostic tests are used for sleep apnoea?
Sleep studies (polysomnography), including pulse oximetry, EEG, respiratory airflow, thoraco-abdominal movement, snoring
26
What is the first-line treatment for moderate or severe sleep apnoea?
Continuous positive airway pressure (CPAP)
27
What management option is available if CPAP is not tolerated or for mild sleep apnoea?
Intra-oral devices such as mandibular advancement devices
28
When should the DVLA be informed in a case of sleep apnoea?
If OSAHS is causing excessive daytime sleepiness
29
What is the role of pharmacological agents in treating sleep apnoea?
There is limited evidence to support their use
30
features of horners syndrome
miosis (small pupil) ptosis enophthalmos* (sunken eye) anhidrosis (loss of sweating one side)
31
causes of horners syndrome
CENTRAL LESIONS - anhydrosis of face arms and trunk Stroke Syringomyelia Multiple sclerosis Tumour Encephalitis PRE-GANGLIONIC LESION - anhydrosis of face Pancoast's tumour Thyroidectomy Trauma Cervical rib POST-GANGLIONIC LESION - no anhydrosis Carotid artery dissection Carotid aneurysm Cavernous sinus thrombosis Cluster headache
32
What is the classic triad of pulmonary embolism?
Pleuritic chest pain, dyspnoea, haemoptysis (seen in only ~10% of patients)
33
Which symptom is most common in pulmonary embolism according to PIOPED?
Tachypnoea (respiratory rate > 20/min, seen in 96%)
34
What are the common clinical signs of pulmonary embolism and their frequencies?
Tachypnoea 96%, Crackles 58%, Tachycardia 44%, Fever 43%
35
What does the Pulmonary Embolism Rule-out Criteria (PERC) help with?
Rules out PE in patients with low clinical probability (<15%) if all criteria are negative
36
What is the negative predictive value of PERC?
Reduces PE probability to <2%
37
What are the components of the 2-level PE Well's score?
1. Clinical signs of DVT (3) 2. PE more likely than other diagnosis (3) 3. HR >100 bpm (1.5) 4. Immobilisation >3 days or surgery in last 4 weeks (1.5) 5. Previous DVT/PE (1.5) 6. Haemoptysis (1) 7. Malignancy (1)
38
What are the cut-offs for 2-level PE Well's score?
PE likely: >4 points; PE unlikely: ≤4 points
39
How should a patient with a 'likely' PE (Wells >4) be managed?
Arrange immediate CTPA; if delayed, start interim therapeutic anticoagulation (preferably DOAC)
40
How should a patient with an 'unlikely' PE (Wells ≤4) be managed?
Arrange D-dimer test; if positive, perform CTPA with interim anticoagulation if delayed; if negative, PE is unlikely
41
When is CTPA preferred over V/Q scan?
CTPA is first-line for non-massive PE; faster, available out-of-hours, provides alternative diagnoses
42
When is V/Q scan preferred over CTPA?
If CXR is normal, patient has no significant cardiopulmonary disease, or there is renal impairment
43
What does a negative CTPA mean for PE management?
PE is effectively excluded and no further PE investigations are needed
44
What is the sensitivity of D-dimer for PE?
95-98% (but poor specificity)
45
How should D-dimer be interpreted in patients over 50 years old?
Use age-adjusted D-dimer thresholds
46
What is the classic ECG change seen in PE?
S1Q3T3 (large S in lead I, large Q in lead III, inverted T in lead III) Other changes Right bundle branch block, right axis deviation, or sinus tachycardia
47
What is the role of chest x-ray in PE?
Mainly to exclude other causes; PE often shows a normal CXR
48
What are possible CXR findings in PE?
Normal, or wedge-shaped opacification
49
What is the sensitivity and specificity of V/Q scan for PE?
Sensitivity ~75%, specificity ~97%
50
What is a limitation of CTPA in detecting PE?
May miss peripheral emboli affecting subsegmental arteries
51
What are the key pulmonary function test patterns for obstructive vs. restrictive lung disease?
Obstructive: FEV1 significantly reduced FVC reduced or normal FEV1/FVC reduced Restrictive: FEV1 reduced FVC significantly reduced FEV1/FVC normal or increased
52
Give 4 examples of obstructive lung diseases.
Asthma, COPD, Bronchiectasis, Bronchiolitis obliterans
53
Give 4 examples of restrictive lung diseases.
Pulmonary fibrosis, Asbestosis, Sarcoidosis, ARDS, Infant respiratory distress syndrome Kyphoscoliosis e.g. ankylosing spondylitis Neuromuscular disorders Severe obesity
54
Which non-pulmonary conditions can cause restrictive lung disease?
Kyphoscoliosis, Neuromuscular disorders, Severe obesity
55
Front
Back
56
What is Alpha-1 antitrypsin (A1AT) deficiency?
An inherited condition caused by deficiency of A1AT, a protease inhibitor that protects tissues from enzymes like neutrophil elastase. Causes early-onset emphysema in non-smokers.
57
What chromosome is the A1AT gene located on?
Chromosome 14
58
How is Alpha-1 antitrypsin deficiency inherited?
Autosomal recessive / co-dominant
59
What are the normal and abnormal A1AT alleles?
M = normal, S = slow, Z = very slow
60
Which A1AT genotype usually manifests disease?
PiZZ (10% of normal A1AT levels)
61
What are the lung features of A1AT deficiency?
Panacinar emphysema, most marked in lower lobes
62
What are the liver features of A1AT deficiency?
Cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
63
What investigations are used for A1AT deficiency?
Serum A1AT levels and spirometry (obstructive picture)
64
What is the management of A1AT deficiency?
No smoking, bronchodilators, physiotherapy, IV A1AT protein concentrates, lung volume reduction or transplantation
65
0
1
66
Key indications for NIV?
1. COPD with respiratory acidosis (pH 7.25–7.35) 2. Type II RF from chest wall deformity, neuromuscular disease, or OSA 3. Cardiogenic pulmonary oedema unresponsive to CPAP 4. Weaning from intubation
67
NIV use in severe acidosis (pH < 7.25)?
Can be used with close monitoring (HDU) and low threshold for intubation
68
Initial BiPAP settings in COPD?
IPAP 10–15 cmH₂O (RCP 10, BTS 12–15) EPAP 4–5 cmH₂O Backup rate 15/min I:E ratio 1:3
69
management of superior vena cava syndrome
dexamethasone, chemo/RT/stenting
70
anticoagulation in PE
Thrombolysis with alteplase or streptokinase if haemodynamically stable or submassive PR with RV dysfunction or elevated troponin otherwise: 1. NOAC 2. LMWH, warfarin, dabigatran Renal impairment or antiphospholipid syndrome Warfarin with LMWH bridging Pregnant LMWH continue until at least 6 weeks post-partum
71
management of asthma
1. AIR therapy ICS/LABA budesonide/formoterol 100/6 PRN 2. Low Dose MART ICS/LABA budesonide/fomoterol 100/6 regularly and PRN 3. Moderate Dose MART ICS/LAB 200/6 4. check FeNO and blood eosinophil count if raised - refer to asthma specialist if normal - trial LTRA or LAMA
72
new investigations for Asthma
1. FeNO >35 confirms asthma 2. Spirometry with bronchodilator reversibility: FEV increase >12% confirms asthma 3. PEFR variability >20% confirms asthma
73
what is an exudative pleural effusion
protein >30 Malignancy Infection (e.g. empyema due to bacterial pneumonia) Trauma Pulmonary infarction Pulmonary embolism people older than 30 tend to make home and stay local
74
what is a transudative pleural effusion
protein <30 Congestive heart failure Liver cirrhosis Severe hypoalbuminemia Nephrotic syndrome lots of trannys less than 30 wear less and have a lot going on
75
pleural fluid pH <7.2 indicates?
infected or complicated parpneumonic effusion/empyema
76
what is lights criteria
used when pleural fluid protein is 25-35 effusion is exudative if ANY of: pleural fluid LDH >2/3 upper limit of serum LDH Pleural fluid/serum LDH ration >0.6 Pleural fluid/serum protein ration >0.5
77
Management of cystic fibrosis
General - high calorie diet exercise Pulmonary- Mucoactive agents rhDNase (dornase Alfa) Prophylactic flucloxacillin until age 3-6 Immunomodulatory azithromycin if deteriorating PFTs GI- Creon Ursodexoycholic acid if deranged LFTs
78
Most common gene mutation in cystic fibrosis
DeltaF508
79
Gold standard investigation for cystic fibrosis
Sweat chloride greater than 60 mol/L
80
Management of bronchiectasis
Chest physio Vaccines annual flu and pneumococcal LABA (e.g. formoterol) if SOB LTOT if PaO2 less than 7.3 or SpO2 less than 88% Prophylactic azithromycin or erythromycin if more than 3 exacerbations in a year Inhaled coils Tim if pseudomonas colonisation Infective exacerbation Amox clarithromycin or doxycycline for 14 days If high risk/severe co-amox or levofloxacin Admit if temp greater than 38 or confused
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83
Antibody assoc with good pastures
anti-glomerular basement membrane
84
Anticoagulant for PE in CKD 4-5
Warfarin with bridging lmwh
85
Anticoagulation for PE in antiphospholipid syndrome
Warfarin with bridging lmwh
86
PTH secreting lung cancer
Squamous cell
87
ACTH secreting lung cancer
Small cell
88
Beta HCG secreting lung cancer and what does this lead to
Large cell lung cancer gynaecomastia
89
SIADH lung cancer
Sclc
90
Cherry red ball on bronchoscopy
Carcinoid lung cancer
91
Gynaecomastia and non smoker which type of lung cancer
Adenocarcinoma
92
Management of pulmonary fibrosis
Nintedanib pirfenidone
93
Lambert Eaton myasthenia is associated with with which cancer
Small cell lung cancer
94
Cancer assoc with myasthenia graves
Thymoa or thymus hyperplasia
95
Allergic rhinitis treatment
Mild to moderate prn intranasal or oral antihistamine Severe regular intranasal steroid
96
Pulmonary hypertension management
Perform acute vasodilator testing Positive AVT - CCB nifedipine Negative AVT - iloprost, bosentan sildenafil
97
India ink stain on csf
Cryptococcal meningitis
98
Management of cystic fibrosis
High calorie diet, exercise Mucoactive agents: rhDNase (Dornase alfa) Prophylactic fluclox until age 3 Azithromycin if deteriorating pulmonary function tests Creon Ursodexoxycholic acid if deranged lfts
99
Restrictive lung pattern with first degree heart block think in young man
Ankolysisng spondylitis
100
Treatment of psittaci pneumonitis
Doxycycline
101
Causative organism of secondary infection post influenza a
Staph aureus
102
Rust coloured sputum
Strep pneumoniae
103
Young patient copd and liver disease
Alpha 1 antitrypsin deficiency
104
Kartageners syndrome triad
Bronchiectasis Dextrocardia Subfertility/infertility
105
T wave inversion in V1 -V3
Pulmonary embolus
106
Management of idiopathic pulomonsry fibrosis
Nintedanib, pirfenidone
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