Respiratory

Question 1

Most common causative organism for exacerbation of COPD?

Answer 1

The most common infective causes of COPD exacerbations are:

• Haemophilus influenzae (most common cause)
• Streptococcus pneumoniae
• Moraxella catarrhalis
• Respiratory viruses account for around 30% of exacerbations
• Human rhinovirus is the most important pathogen

Question 2

Centor criteria?

Answer 2

Estimates probability that pharyngitis is streptococcal:

Cough absent
Exudate (tonsillar)
Nodes (tender cervical lymphadenopathy)
Temperature >38

Question 3

FeverPain score?

Answer 3

1 point each for:

Fever in last 24h

Purulence (tonsillar exudate)

Attend rapidly (within 3 days of symptom onset)

Inflamed tonsils (severely inflamed)

No cough or coryza

Question 4

First line Abx for IECOPD?

Answer 4

First-line: Amoxicillin or Clarithromycin or Doxycycline

Question 5

Management for occupational asthma?

Answer 5

Referral should be made to a respiratory specialist for patients with suspected occupational asthma.

Question 6

COPD management stepwise?

Answer 6

1. SABA or SAMA

Asthmatic features or features of steroid responsiveness?

Yes:
2. LABA + ICS + SABA/SAMA PRN

No:
2. LABA + LAMA + SABA PRN

3. LABA + LAMA + ICS + SABA PRN

Question 7

Which tests to monitor before starting patients on long term prophylactic antibiotic therapy for COPD?

Answer 7

Oral prophylactic antibiotic therapy
azithromycin prophylaxis is recommended in select patients. Not recommended if patients continue to smoke

Patients should not smoke, have optimised standard treatments and continue to have exacerbations
other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis).

LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval.

Question 8

PEFR in moderate, severe and life threatening asthma?

Answer 8

Moderate:
PEFR > 50% best or predicted
RR < 25
Pulse < 110 bpm

Severe:
PEFR 33 - 50% best or predicted
RR > 25
Pulse > 110 bpm

Life threatening:
PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension

Question 9

Features of aspergilloma?

Answer 9

Pre-existing lung cavity → from TB, sarcoidosis, bronchiectasis, emphysema, or previous abscess.

The cavity provides a space with necrotic tissue/debris.
Aspergillus fumigatus spores colonise this cavity (but don’t invade the surrounding lung tissue).

The fungus grows into a tangled mass of hyphae, mucus, inflammatory cells, and fibrin → forming a fungal ball that moves within the cavity.

🔹 Clinical features:
- Often asymptomatic.
- Can present with haemoptysis (sometimes massive, because aspergilloma erodes into nearby blood vessels).

Seen on imaging as a mobile intracavitary mass with an air crescent around it.

Question 10

How does mitral stenosis cause haemoptysis?

Answer 10

Dyspnoea + haemoptysis

Loud first heart sound + diastolic murmur → classic for mitral stenosis

New atrial fibrillation → very common complication of mitral stenosis due to left atrial enlargement

🔹 Pathophysiology:

In mitral stenosis, the left atrium dilates because it struggles to empty into the LV.

Dilated LA → ↑ pressure in pulmonary veins → pulmonary venous congestion → rupture of thin-walled bronchial/pulmonary veins → haemoptysis.

Question 11

Lung cancer referral guidelines?

Answer 11

1. Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:
   - Have chest x-ray findings that suggest lung cancer
   - Aged 40 and over with unexplained haemoptysis

Offer an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms or if they have ever smoked and have 1 or more of the following unexplained symptoms:
- cough
- fatigue
- shortness of breath
- chest pain
- weight loss
- appetite loss

Consider an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following:
- persistent or recurrent chest infection
- finger clubbing
- supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- chest signs consistent with lung cancer
- thrombocytosis

Question 12

First line investigations for suspected asthma in adults?

Answer 12

1. First-line investigations:
   - Measure the eosinophil count OR fractional nitric oxide (FeNO).
   Diagnose asthma without further investigations if:
   - Eosinophil is above the reference range
   - FeNO is ≥ 50 ppb
2. If asthma is not confirmed by the eosinophil count or FeNO
   measure bronchodilator reversibility (BDR) with spirometry
   diagnose asthma if:
   - the FEV1 increase is ≥ 12% and 200 ml or more from the pre-bronchodilator measurement or
   the FEV1 increase is ≥ 10% of the predicted normal FEV1
   - If spirometry is not available or it is delayed measure peak expiratory flow (PEF) twice daily for 2 weeks
   diagnose asthma if:
   PEF variability (expressed as amplitude percentage mean) is ≥ 20%

If asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability but still suspected on clinical grounds:
- Refer for consideration of a bronchial challenge test
- Diagnose asthma if bronchial hyper-responsiveness is present

Question 13

Vaccinations for COPD?

Answer 13

Patients with COPD should receive an annual influenza vaccination and a one-off pneumococcal vaccination

Question 14

Causes of clubbing?

Answer 14

Cardiac causes:
- Cyanotic congenital heart disease (Fallot’s, TGA)
- Bacterial endocarditis
- Atrial myxoma

Respiratory causes:
- Lung cancer
- Pyogenic conditions: cystic fibrosis, bronchiectasis, abscess, empyema
- Tuberculosis
- Asbestosis, mesothelioma
- Fibrosing alveolitis

Other causes:
- Crohn’s, to a lesser extent UC
- Cirrhosis, primary biliary cirrhosis
- Graves’ disease (thyroid acropachy)
rare: Whipple’s disease

NOT COPD

Question 15

Asthma step up management?

Answer 15

1. Low dose ICS/Formoterol PRN
   - if the patient presents highly symptomatic (regular nocturnal waking) or with a severe exacerbation:
   - start treatment with low-dose MART
   - treat the acute symptoms as appropriate (oral corticosteroids may be indicated)
2. Low-dose MART
   MART describes using an inhaled corticosteroid (ICS)/formoterol combination inhaler for daily maintenance therapy and the relief of symptoms as needed (regularly and PRN)
3. Moderate dose MART
4. Check FeNO level and blood eosinophil count
   - 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 LTRA)or a 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)
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 16

When to notify DVLA for OSA?

Answer 16

The DVLA must be notified for mild, moderate or severe OSA causing excessive daytime sleepiness.

The DVLA must be notified in all cases of OSA in group 1 drivers where there is the persistence of excessive daytime sleepiness (Epworth score > than, or equal to, 11).

This man has mild OSA - defined as an apnoea/hypopnoea index score of 5-15/hour and if not causing excessive daytime sleepiness, he would not have to notify the DVLA.

For moderate and severe OSA, the DVLA must be notified and the sleep clinic needs to ensure symptoms controlled before he would be able to drive.

Question 17

How is LTOT supplied?

Answer 17

Oxygen concentrator via Home Oxygen Order Form

Question 18

Common organisms for bronchiectasis?

Answer 18

Most common organisms isolated from patients with bronchiectasis:

• Haemophilus influenzae (most common)
• Pseudomonas aeruginosa
• Klebsiella spp.
• Streptococcus pneumoniae

Question 19

Bronchiectasis managment?

Answer 19

After assessing for treatable causes (e.g. immune deficiency) management is as follows:

• physical training (e.g. inspiratory muscle training) - has a good evidence base for patients with non-cystic fibrosis bronchiectasis
• postural drainage
• antibiotics for exacerbations + long-term rotating antibiotics in severe cases
• bronchodilators in selected cases
• immunisations
• surgery in selected cases (e.g. Localised disease)

Question 20

Lung function tests and examples of obstructive lung disease?

Answer 20

FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced

Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans

Question 21

Lung function tests and examples of restrictive lung disease?

Answer 21

FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased

Pulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis e.g. ankylosing spondylitis
Neuromuscular disorders
Severe obesity

Question 22

CRB 65 parameters?

Answer 22

Confusion (abbreviated mental test score <= 8/10)
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years

Score 0 : Low risk
NICE recommend that treatment at home should be considered (alongside clinical judgement)
1 or 2: intermediate risk (1-10% mortality risk)
NICE recommend that ‘ hospital assessment should be considered (particularly for people with a score of 2)’
3 or 4: high risk (more than 10% mortality risk)
NICE recommend urgent admission to hospital

Question 23

Malignancies where raised platelets can be seen?

Answer 23

PLT cancers = LEGO - C
Lung
Endometrial
Gastro-oesophageal
Ovarian
Colorectal

Question 24

Examples of different classes of inhaler?

Answer 24

SABA
Bronchodilator, rapid onset, lasts ~4 hours
- Salbutamol (Ventolin)
- Terbutaline

SAMA
Anticholinergic bronchodilator, lasts ~4–6 hours
- Ipratropium bromide

LABA
Bronchodilator, lasts ~12–24 hours
- Formoterol (fast onset, can be used in MART)
- Salmeterol (slower onset)

LAMA
Anticholinergic bronchodilator, lasts ≥24 hours
- Tiotropium
- Glycopyrronium

Question 25

Diagnosis of idiopathic pulmonary fibrosis?

Answer 25

- Progressive exertional dyspnoea - Bibasal fine end-inspiratory - crepitations on auscultation - dry cough - clubbing Diagnosis - Spirometry: classically a restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased) - Impaired gas exchange: reduced transfer factor (TLCO) - Imaging: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - 'ground-glass' - later progressing to 'honeycombing') may be seen on a chest x-ray but high-resolution CT scanning is the investigation of choice and required to make a diagnosis of IPF - ANA positive in 30%, rheumatoid factor positive in 10% but this does not necessarily mean that the fibrosis is secondary to a connective tissue disease. Titres are usually low

Question 26

Mx for idiopathic pulmonary fibrosis?

Answer 26

- Pulmonary rehabilitation very few medications have been shown to give any benefit in IPF. - There is some evidence that pirfenidone (an antifibrotic agent) may be useful in selected patients - Many patients will require supplementary oxygen and eventually a lung transplant

Question 27

What are the asthmatic features suggesting steroid responsiveness in COPD?

Answer 27

1. Any previous, secure diagnosis of asthma or of atopy 2. Higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up 3. Substantial variation in FEV1 over time (at least 400 ml) 4. Substantial diurnal variation in peak expiratory flow (at least 20%)

Question 28

Bronchiectasis finding on CXR?

Answer 28

Parallel line shadows (often called tram lines) are common in bronchiectasis and indicate dilated bronchi due to peribronchial inflammation and fibrosis

Question 29

Diagnostic Ix for OSA?

Answer 29

sleep studies (Polysomnography) - ranging from monitoring of pulse oximetry at night to full polysomnography where a wide variety of physiological factors are measured including EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry

Question 30

Investigation for diagnosis of asthma in children aged 5 to 16?

Answer 30

1. First-line investigation NICE measure the fractional nitric oxide (FeNO) diagnose asthma if: FeNO is ≥ 35 ppb If the FeNO level is not raised, or if FeNO testing is not available: 2. Measure bronchodilator reversibility (BDR) with spirometry diagnose asthma if: the FEV1 increase is ≥ 12% from the pre-bronchodilator measurement, or the FEV1 increase is ≥ 10% of the predicted normal FEV1 3. if spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks diagnose asthma if: PEF variability (expressed as amplitude percentage mean) is ≥ 20% 4. If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds: perform skin prick testing to house dust mite OR measure total IgE level and blood eosinophil count exclude asthma if there is no evidence of sensitisation to house dust mite on skin prick testing OR if the total serum IgE is not raised diagnose asthma if there is evidence of sensitisation OR a raised total IgE level and the eosinophil count is > 0.5 x 109/L 5. If there is still doubt about the diagnosis refer to a paediatric specialist for a second opinion, including consideration of a bronchial challenge test

Question 31

What findings support diagnosis of asthma?

Answer 31

According to current guidance the following findings support a diagnosis of asthma: - Eosinophil count is above the laboratory reference range - FeNO level is 50 ppb or more. - If the FEV1 increase is 12% or more and 200 ml or more from the pre-bronchodilator measurement on spirometry. - If Peak Expiratory Flow variability is 20% or more.

Question 32

DVLA rules for OSA?

Answer 32

A person with suspected OSA syndrome must stop driving immediately if they have excessive sleepiness. They need only notify the DVLA if control of symptoms is not achieved within three months. If moderate or severe OSAS is diagnosed, the DVLA must be notified with review every three years as a minimum.