1
Q
What is acute bronchitis?
A
A lower respiratory tract infection characterised by inflamed bronchi
2
Q
What is the main cause of acute bronchitis?
A
90% Viral (Rhino, Adeno, Corona)
10% Bacterial (Strep Pneum, H. Influenzae)
3
Q
What is the likely diagnosis in a patient with a recent URTI and a persistent productive cough without fever or significant CXR findings?
A
Acute Bronchitis
4
Q
What typically precedes acute bronchitis?
A
A URTI with a productive or non-productive cough that resolves within 2-3 weeks
5
Q
What are the respiratory examination findings for acute bronchitis?
A
Wheeze
6
Q
If a patient presents with recurrent acute bronchitis, what should you consider?
A
Asthma or COPD, consider doing spirometry with BDR
7
Q
What is seen on CXR for acute bronchitis?
A
Normal CXR
8
Q
What is the management for acute bronchitis?
A
Conservative (Supportive, Analgesia)
9
Q
What is the management for acute bronchitis in systemically very unwell patients?
A
1st: 5 day course of doxycycline
2nd: 5 day course of amoxicillin
10
Q
What CRP levels could indicate the need for antibiotic treatment in acute bronchitis?
A
CRP < 20 mg/L = do not routinely offer antibiotics
CRP 20-100 mg/L = consider delayed antibiotic prescription
CRP > 100 mg/L = offer antbiotic therapy::next step
11
Q
A 15 year old asthmatic patient has worsening dyspnoea, wheeze, & cough that is refractory to their salbutamol inhaler. The patient cannot complete full sentences & has a RR of 29. What is the most likely diagnosis?
A
Severe asthma exacerbation
12
Q
How is PEFR affected in acute asthma exacerbations?
A
Moderate = PEFR 50-75% best or predicted
Severe = PEFR 33-50% best or predicted
Life-threatening = PEFR < 33% best or predicted
13
Q
How is speech affected in acute asthma exacerbations?
A
Moderate = Speech normal
Severe = Speech cannot complete sentences
Life-threatening = …
14
Q
How is resp rate affected in acute asthma exacerbations?
A
Moderate = RR < 25/min}
Severe = RR ≥ 25/min
Life-threatening = …
15
Q
How is pulse affected by acute asthma exacerbations?
A
Moderate = pulse < 110/min
Severe = pulse ≥ 110/min
Life-threatening = …
16
Q
How are O2 sats affected by acute asthma exacerbations?
A
Life-threatening = <92%
17
Q
What are signs of life-threatening acute asthma exacerbations?
A
Silent chest, cyanosis, bradycardia, hypotension, exhaustion, or confusion
18
Q
What can acute asthma exacerbations be triggered by?
A
Respiratory tract infections
19
Q
What does an acute asthma attack with normal pCO2 indicate?
A
A lack of respiratory effort and therefore a life-threatening exacerbation
20
Q
What does an acute asthma attack with raised pCO2 indicate?
A
A continued lack of respiratory effort and therefore a near fatal exacerbation
21
Q
What is the management for asthma exacerbations?
A
Oxygen
Salbutamol Nebuliser
Hydrocortisone IV
Ipratropium Bromide nebuliser
Theo/Amino phylline
Magnesium Sulphate IV
Escalate
22
Q
What does an FEV1/FVC ratio of 70% indicate?
A
Obstructive lung disease
23
Q
What is the main difference between asthma and COPD?
A
Obstruction in asthma is reversible, whereas obstruction in COPD is irreversible
24
Q
What is asthma?
A
An inflammatory disease characterized by hyper-responsive airways. Airway obstruction is reversible. There is inappropriate smooth muscle contraction.
25
When does asthma typically develop?
Childhood
26
What is asthma commonly associated with?
Allergic rhinitis, eczema and family history of atopy
27
What can often trigger asthma?
Allergens like pollen, house dust mite, pollution, pet dander, smoke
28
What times of day is asthma worse?
Early morning and nighttime
29
What factors can make asthma worse?
Exercise, cold weather
30
What medications should be avoided in patients with asthma?
BAN
Betablockers
Aspirin
NSAIDS
31
What is the "hygiene hypothesis"?
Asthma is more common in developed countries because of a reduced exposure to infectious agents & allergens preventing normal development of immune system resulting in a T-helper 2 response to antigens instead of tolerance
32
What is occupational asthma?
Asthma related to allergens in the workplace
33
What are the main symptoms of asthma?
Dry cough, dyspnoea, chest tightness
34
What is the main sign of asthma upon ascultation?
Wheeze
35
What are the diagnostic investigations in an adult with suspected asthma?
Eosinophil count & fractional exhaled nitric oxide (FeNO)
36
What tests can be used if the first line investigation for asthma is negative?
Spirometry with a bronchodilator reversibility (BDR) test ≥ 12% or 200ml
37
What are the diagnostic investigations in a child 5 -16 years old with suspected asthma?
Fractional exhaled nitric oxide (FeNO)
38
What are the diagnostic investigations in a child <5 years old with suspected asthma?
Clinical diagnosis
39
What is the step-wise management of asthma in a patient older than 12?
1. Newly diagnosed → low-dose ICS/formoterol combination inhaler PRN
2. Not controlled on previous step or highly symptomatic → low-dose MART
3. Not controlled on previous step → moderate-dose MART
4. Not controlled on previous step → check adherence to medication, FeNO + blood eosinophil count
If raised → refer to asthma specialist
If not raised → LTRA or LAMA + moderate-dose MART for 8-12 weeks
If not improved on LTRA or LAMA then stop the current drug and trial the alternative drug class (LTRA or LAMA)
5. Not controlled on previous step → refer to asthma specialist
40
Give an example of each medication used in the stepwise management of asthma (SABA, ICS, LTRA, LABA)
SABA: salbutamol
ICS: budesonide, bedomethasone, fluticasone
LTRA: montelukast
LABA: formeterol, salmeterol
41
What are MART and Symbicort?
MART = maintenance & reliever therapy = ICS + formeterol
Symbicort = budesonide/formeterol (ICS/LABA)
42
Which monoclonal antibody can be used to treat allergic asthma, especially in patients refractory to corticosteroids?
Omalizumab
43
How is asthma monitored over time?
Review asthma control (time off work/school, reliever uses, admissions to hospital and oral steroids needed)
44
What does red-currant sputum indicate?
Klebsiella pneumonia
45
Which pneumonia-causing organism is associated with autoimmune haemolytic anaemia and erythema multiforme in young adults?
Mycoplasma pneumoniae}
46
Which pneumonia-causing organism is associated with contaminated air conditioning/water systems, hyponatraemia and low levels of lymphocytes on FBC?
Legionella pneumophilia
47
What is the management of mycoplasma pneumoniae infection?
Tetracycline (e.g Doxycycline) or a macrolide (e.g. erythromycin in pregnancy)
48
What is the diagnostic investigation for mycoplasma pneumoniae?
Blood serology - Positive Mycoplasma IgM and/or increase in IgG 2-4 weeks later
(Or Positive Cold Agglutination test)
49
What are common complications of mycoplasm pneumoniae?
Encephalitis, autoimmune haemolytic anaemia, erythema multiforme
50
What would a CXR of a patient with mycoplasma pneumoniae show?
Bilateral consolidation?
51
What is mycoplasma pneumoniae?
Mycoplasma pneumoniae is an aytipical pneumonia which is more common in younger patients
52
How does mycoplasma pneumoniae present?
A gradual onset of flu-like symptoms which are typically preceded by a non-productive cough
53
What is bronchiectasis the main complication of?
Hypogammaglobulinemia
54
What initial investigations may be useful in patients with suspected bronchiectasis?
Sputum culture, CXR, Spirometry, FBC
55
What is the best diagnostic investigation for bronchiectasis?
High resolution CT
56
What can be heard upon auscultation of bronchiectasis?
Coarse inspiratory crepitations & wheeze
57
How does bronchiectasis usually present?
Bronchiectasis usually presents with a productive cough which produces a large volume of purulent sputum and occasionally haemoptysis
58
What is bronchiectasis?
A permanent dilation of the bronchi as a result of permanent damage from inflammation and infection
59
How are exacerbations/ severe case of bronchiectasis treated?
Antibiotics
Sputum clearance: mucolytics + postural drainage!
60
What could patients with bronchiectasis secondary to allergic bronchopulmonary aspergillosis be treated with?
Prednisolone
61
Patients with suspected bronchiectasis should be tested for what allergy?
allergic bronchopulmonary aspergillosis
62
What changes are seen in a CXR of a patient with bronchiectasis?
Thickened bronchial walls, cystic appearance (tramline and ring shadows)
63
What sign do the hands of patients with bronchiectasis often have?
Finger clubbing
64
What are the most common causative agents of infections in patients with bronchiectasis?
Haemophilus influenzae, Pseudomonas aeruginosa, Streptococcus Pneumoniae, Staphylococcus aureus
65
How is a wheeze treated in a patient with bronchiectasis?
Bronchodilators
66
What is conservative management of bronchiectasis?
Patient education, smoking cessation and chest physiotherapy
67
What should patients with a history of rheumatoid arthritis and frequent respiratory infections or long-term productive cough be investigated for?
Bronchiectasis?
68
How are COPD exacerbations managed in secondary care?
Oxygen, nebulised bronchodilators, prednisolone
69
How should acute exacerbations of COPD that don't respond to nebulised bronchodilators be treated?
IV theo/amino phylline
70
What should the target O2 sats be for patient with COPD exacerbations?
Oxygen saturation target for exacerbations should be 88-92%.
If pCO2 is normal, this should be adjusted to 94-98%
71
When should COPD exacerbations be treated in hospital?
If oxygen saturations are less than 90%
Severe breathlessness
Acute confusion or impaired consciousness
Cyanosis
Oxygen saturation less than 90% on pulse oximetry
Social reasons
Significant comorbiditiy (e.g. insulin dependent diabetic, cardiac disease)
72
What is the out of hospital management of COPD exacerbations?
Increase bronchodilators, prednisolone (5 days), consider ABX (if there are signs of pneumonia)
73
What does confusion in COPD exacerbations indicate?
Hypoxia
74
What is the likely cause of a COPD exacerbation with increased sputum?
Infective
75
What is the most common cause of COPD exacerbations?
Viruses; the most common is rhinovirus
76
What is th emost common bacterial cause of COPD exacerbations?
Haemophilus influenzae
77
What should patients who develop type 2 respiratory failure during a COPD exacerbation be given if they have hypercapnic ventilatory failure?
Non-invasive ventilation (BiPaP)
78
What is the treatment for patients who experience COPD exacerbations/ are still limited by symptoms after inhaled therapy?
Patients without asthmatic features or steroid responsiveness:
1st line: LABA + LAMA
2nd line (persistent symptoms/exacerbations): triple therapy (LABA + LAMA + ICS)
Patients with asthmatic features or steroid responsiveness:
1st line: LABA + ICS
2nd line (persistent symptoms/exacerbations): triple therapy (LABA + LAMA + ICS)
79
What is the initial inhaled therapy management of COPD?
SABA or SAMA as needed
80
When should inhaled therapy be offered to patients with COPD?
If there is breathlessness and exercise limitation
81
What vaccinations should COPD patients recieve?
Annual influenza vaccination and a one-off pneumococcal vaccination
82
What non-pharmacological treatments/lifestyle changes are recommended for COPD patients?
Smoking cessation & Pulmonary rehabilitation
83
What is the main cuase of COPD?
Smoking
(Exposure to other respiratory irritants is also a risk factor)
84
What genetic change predisposes someone to COPD?
Alpha-1 antitrypsin deficiency
85
What are the post-bronchodilator FEV1 stages of COPD?
Mild (Stage 1): ≥80%
Moderate (Stage 2): 50-79%
Severe (Stage 3): 30-49%
Very Severe (Stage 4): <30%
86
What is LTOT and when should it be used in patients with COPD?
Long term oxygen therapy
LTOT must be administered for at least 15 hours each day for there to be a survival benefit in COPD patients
87
Who is LTOT not offered to?
Smokers
88
When is LTOT offered to patients with COPD?
If they have a PO2 <7.3kPa or PO2 7.3-8kPa and secondary polycythaemia, peripheral oedema or pulmonary hypertension
89
How is long term oxygen therapy assessed in patients with COPD?
2x ABG done 3 weeks apart
90
What is the symptomatic management of Cor Pulmonale in COPD patients?
Diuretics (e.g. Loop diuretic)
(Consider LTOT)
91
What may COPD patients with a chronic productive cough be offered?
Mucolytics (e.g. carbocisteine)
92
What ECG changes can azithromycin cause?
QT prolongation
93
What may patients with COPD who continue to have exacerbations while on standard treatments be offered?
Prophylactic ABX (azithromycin)
94
What tests need to be done prior to the prescription of prophylactic azithromycin?
LFT and ECG
95
What should be done if theo/amino phylline and macrolides/fluoroquinolones are co-prescribed?
The dose of theophylline should be reduced
Phosphodiesterase inhibitor - relaxes smooth muscle
Interaction with macrolides can cause cardiac complications including (torsades de pointes - type of VT)
96
What may Patients with COPD who have had trials of short and long acting bronchodilators or are unable to use inhaled therapies be offered?
Oral theophylline
97
Why must you do an FBC in a patient with suspected COPD?
To rule out secondary polycythemia
98
What may a CXR of a patient with COPD show?
Hyperinflation, bullae, diaphragm flattening
99
What investigations may be done for suspected COPD?
Post-bronchodilator spirometry, CXR, FBC
100
What should Patients <40 years old OR minimal smoking history with suspected COPD be tested for?
Alpha-1 antitrypsin deficiency
101
What are the features of COPD?
chronic productive cough, exertional dyspnoea, wheeze, right-sided heart failure (Cor pulmonale) and recurrent chest infections
102
What is COPD?
Chronic obstructive pulmonary disease (COPD) involves airway obstruction that is usually progressive, encompassing emphysema and chronic bronchitis
103
Is clubbing present in COPD?
Clubbing is NOT present in COPD
If clubbing is present, rule out lung cancer
104
What symptoms can lung cancer present with?
Cough, SOB, chest pain, haemoptysis & weight loss
105
How is hoarseness caused by lung cancer?
Compression of the recurrent laryngeal nerve
106
How is SVC syndrome caused by lung cancer?
Compression of the superior vena cava
107
What presentation does adenocarcinoma typically cause?
Pleural effusion
108
What may be heard on ascultation in lung cancer?
A fixed, monophonic wheeze
109
What may be found on lymph node examination in a patient with lung cancer?
Supraclavicular or persistent cervical lymphadenopathy
110
What are the two main types of lung cancer?
Non-Small Cell Lung Cancer NSCLC (85%)
Small Cell Lung Cancer SCLC (15%)
111
Name the 3 main sub-types of Non-small Cell Lung Cancer
1. Adenocarcinoma (40%)
2. Squamous cell cancer (30%)
3. Large cell cancer (15%)
112
What is the most common type of lung cancer?
Adenocarcinoma (NSCLC)
113
What type of person does small cell lung cancer almost exclusively appear in?
Smokers
114
Which common lung cancer is known to present peripherally?
Adenocarcinoma & large cell cancer
115
Which common lung cancer is known to present centrally?
Small cell and squamous cell
116
Which lung cancers require bronchoscopy and which need percutaneous needle biopsy?
Central = bronchoscopy
Peripheral = percutaneous
117
What are the most common lesions in squamous cell cancer?
Cavitating lesions
118
Which lung cancer is associated with PTH-rp release as a paraneoplastic syndrome?
Squamous cell carcinoma
119
Which lung cancer is associated with hypertrophic pulmonary osteoathropathy (HPOA)?
Non small cell lung cancer
120
Which lung cancer is associated with SIADH as a paraneoplastic syndrome?
Small cell carcinoma
121
Which lung cancer is associated with Cushing's syndrome as a paraneoplastic syndrome?
Small cell carcinoma
122
Which lung cancer is associated with Lambert-Eaton syndrome as a paraneoplastic syndrome?
Small cell carcinoma
123
What hormone may large cell carcinomas secrete?
β-hCG
124
What is the initial investigation for suspected lung cancer?
CXR
125
What is the best investigation for suspected lung cancer?
CT scan
126
How is a lung cancer biopsy taken?
Via bronchoscopy & aided by endotrachial US
127
What investigation is done for non-small cell lung cancer to establish eligibility for curative treatment?
PET scan
128
What blood result may be seen in lung cancer?
Thrombocytosis from cytokine release originating from the tumour
129
How is non-small cell lung cancer typically managed?
Radiotherapy
130
How is small cell lung cancer typically managed?
Chemotherapy + radiotherapy
(Early diagnosis could be a candidate for surgery)
131
Which has a worse prognosis, non-small cell or small cell lung cancer?
Small Cell Lung Cancer tends to have a worse prognosis than Non-small Cell Lung Cancer
132
What are the two main management options for superior vena cava obstruction in lung cancer?
Endovascular stenting (Most effective)
Chemotherapy &/or Radiotherapy
133
What is superior vena cava obstruction?
Impaired venous drainage of the head, neck and upper extremities, leading to oedema and distended superficial veins
134
A patient with known lung cancer presents with facial swelling and a distended jugular vein. What is the most likely diagnosis?
Superior vena cava obstruction
135
What is a rare cause of Superior vena cava obstruction?
Thrombosis of intravascular devices (e.g. central venous catheters, pacemaker leads, or dialysis catheter)
136
What treatment may a patient with superior vena cava obstruction and suspected/knonw lung malignancy be given?
An initial dose of dexamethasone (4mg 6 hourly)
137
How may patients with superior vena cava obstruction present?
Dyspnoea due to venous congestion of the airway
Headache and blurred vision due to raised ICP
138
How does superior vena cava obstruction affect the JVP?
Bilateral non-pulsatile distension
139
What is the gold-standard investigation for superior vena cava obstruction?
CT thorax with contrast
140
What is pneumoconiosis?
A term used to describe a range of interstitial lung diseases caused by inhalation of mineral dusts, resulting in interstitial fibrosis
141
What is asbestosis?
A lung disease caused by long-term exposure to asbestos fibres that was widely used as an insulating & fireproofing material before disease-causing effects were known
142
Who is asbestosis commonly seen in?
Construction workers, shipyard workers, and plumbers
143
How does exposure affect the risk of asbestosis and mesothelioma?
Asbestosis severity is correlated to the levels of exposure
The quantitiy of asbestosis exposure is not correlated to the risk of mesothelioma
144
What does asbestosis typically cause?
Lower lobe fibrosis
145
What fatal complication can asbestosis cause?
Mesothelioma
146
How does asbestosis typically present?
> 50 year old patient with dyspnoea, reduced exercise tolerance, clubbing, & bilateral end-insipratory crackles
147
What do lung function tests for asbestosis show?
A restrictive pattern
148
What is the first-line investigation for suspected asbestosis?
CXR:
- Pleural plaques
- Pleural thickening
- Potential lung cancer
149
What is the management for asbestosis?
Conservative, monitor for lung cancer. Quit smoking
150
What is the management for mesothelioma associated with asbestosis?
Palliative chemotherapy - poor prognosis
151
What is the most common cause of aspiration pneumonia?
People with an unsafe swallow
152
What investigation should be done for all suspected Hospital Acquired Pneumonias?
Sputum culture
153
What are the most common causative organisms of Hospital Acquired Pneumonia?
Pseudomonas aeruginosa, Staphylococcus aureus
154
Patients with moderate-high severity Community Acquired Pneumonia should have what additional investigations?
Blood cultures, sputum cultures, pneumococcal & legionella urinary antigen tests
155
How quickly should diagnosis and treatment of community acquired pneumonia occur after presentation to the hospital?
4 hours
156
What is the first line treatment for community acquired pneumonia in adults?
Oral amoxicillin for 5 days
( 2nd line: Doxycycline/Clarithromycin/Erythromycin (pregnancy) )
157
What is the first line treatment for moderate severe community acquired pneumonia in adults?
Oral amoxicillin + macrolide for 5 days
158
What is the first line treatment for high severity community acquired pneumonia in adults?
Oral co-amoxiclav + macrolide for 5 days
159
When should patients with pneumonia have a repeat CXR?
Approx. 6 weeks after inital CXR
160
What may chest percussion of a pneumonia reveal?
Focal dullness
161
What is Hospital acquired pneumonia?
Pneumonia which develops after 48hrs of hospital admission is classified as hospital acquired pneumonia
162
What are the most common symptoms of pneumonia?
Productive cough & dypnoea
(may present with systemic signs like fever and tachycardia)
163
What could ascultation of a patient with pneumonia show?
Reduced breath sounds, bronchial breathing and coarse crepitations
164
What initial non-bedside investigations should be done for suspected pneumonia?
FBC, U&Es, CRP, Procalcitonin, CXR
165
Define CURB-65
The CURB-65 scoring system is used to assess the severity of community acquired pneumonia in secondary care (hospital)
The CRB-65 scoring system is used to assess the severity of community acquired pneumonia in primary care (GP)
166
How do you calculate CURB-65?
C - Confusion (AMTS ≤8/10)
U - Urea (>7 mmol/L)
R - Respiratory rate (≥ 30/min)
B - Blood pressure (systolic ≤90 mmHg and/or diastolic ≤60 mmHg)
65 - Age ≥65
167
What does each CURB-65 score mean?
0-1 = treat at home
≥2 = hospital admission
≥3 = intensive care
168
What test shouldn't be done in patients with low severity community acquired pneumonia?
Microbiological tests should not be routinely offered to patients with low severity CAP
169
What is the most common type of pneumonia?
Bacterial
170
What organism causes pneumonia associated with cold sores, high fever and rapid onset of symptoms?
Streptococcus pneumoniae
171
Which pneumonia-causing organism infects patients after an influenza infection?
Staphylococcus aureus
172
Which pneumonia-causing organism is commonly seen in alcoholics?
Klebsiella pneumoniae
173
Which pneumonia-causing organism is seen in HIV patients?
Pneumocystis jiroveci (fungal)
174
What is a pneumothorax?
An abnormal collection of air in the pleural space
175
What are the two types of pneumothorax?
Primary = no underlying lung disease
Secondary = underlying lung disease (e.g. COPD, CF, malignancy, pneumonia)
176
What type of patient is primary pneumothorax commonly seen in?
Tall young adults, especially men
177
What is a major lifestyle risk factor for primary pneumothorax?
Smoking
178
What syndrome is a risk factor for primary pneumothorax?
Marfan syndrome
179
What underlying lung diseases can cause secondary pneumothorax?
COPD, cystic fibrosis, lung malignancy, pneumocystis jiroveci pneumonia, sarcoidosis, TB
180
What si the most common cause of iatrogenic pneumothorax?
Mechanical venilation
181
Sudden onset SOB with unilateral pleuritic chest pain with reduced breath sounds & hyperresonance on the affected side. 108bpm & 22 resp rate. What is the likely diagnosis?
Pneumothorax
182
What is the likely diagnosis in a patient with COPD who develops sudden-onset dyspnoea and chest pain with unilaterally decreased breath sounds (no tracheal deviation)?
Secondary spontaneous pneumothorax
183
How do patients with pneumothorax typically present?
Sudden-onset dyspnoea and pleuritic unilateral chest pain that develop at rest
184
What are the signs of pneumothorax?
Hyperresonance to percussion on the affected side
Diminished breath sounds on the affected side
Decreased tactile fremitus on the affected side
185
What is the investigation for pneumothorax?
CXR
186
What are the signs of a pneumothorax on USS?
Absent "lung sliding"
187
What may an ABG show in pneumothorax?
Hypoxaemia or/and respiratory alkalosis due to hyperventilation
188
What is the treatment for asymptomatic primary pneumothorax?
Conservative (regular outpatient review)
189
What is the treatment for asymptomatic secondary pneumothorax?
Conservative (inpatient review)
190
What is the treatment for symptomatic pneumothorax with high risk characteristics?
Chest drain (if safe e.g. ≥2cm)
191
What are high risk characteristics in pneumothorax?
Haemodynamically unstable
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥50 years old with significant smoking history
Haemopneumothorax
192
What is the treatment for symptomatic pneumothorax without high risk characteristics <2cm?
Conservative management
193
What is the management of a symptomatic pneumothorax without high risk characteristics ≥2cm in a patient that would like to avoid a procedure?
Conservative management
194
What is the management of a symptomatic pneumothorax without high risk characteristics ≥2cm in a patient that would like rapid symptom relief AND to go home?
Ambulatory device (review as outpatient)
195
What is the management of a symptomatic pneumothorax without high risk characteristics ≥2cm in a patient that would like rapid symptom relief (ambulatory device unavailable)?
Needle aspiration
196
What is the management of an iatrogenic pneumothorax from ventilation?
Chest drain
197
What is the management of recurrent pneumothorax?
Consider video-assisted thoracoscopic surgery (VATS) to allow mechanical/checmical pleurodesis +/- bullectomy
198
What is the flying advice after a resolution of a pneumothorax?
Flying as an absolute contraindication for 1 week post CXR confirmation
199
What is the scuba diving advice after a pneumothorax?
Absolute contraindication
200
What should you do if needle aspiration of a pneumothorax does not resolve symptoms?
Insert chest drain
201
What is a tension pneumothorax?
A one-way valve that causes increased pressure in the affected lung, it is a medical emergency
202
What is a key sign in tension pneumothorax?
Jugular vein distension with absent breath signs on the affected side
The mediastinum (and hence, trachea) deviate away from the affected side
Hyperresonance on the affected side
203
What are common causes of tension pneumothoraces?
Traumatic chest injuries or mechanical ventilation
204
What is the main complication of tension pneumothorax?
Tension pneumothorax results in a rapid rise in intra-thoracic pressure, impeding venous return to the heart and potentially leading to CARDIAC ARREST if left untreated
205
What is the biggest differentiator between a simple pneumothorax vs tension pneumothorax?
Worsening clinical signs e.g. haemodynamically unstable
206
What is the investigation for tension pneumothorax?
CLINICAL! Do not waste time on waiting for a CXR
207
What is the management of a tension pneumothorax?
Needle decompression (with a large bore cannula) at the 2nd mid clavicular line → chest drain
208
How does a pulmonary embolism present?
Pleuritic chest pain, dyspnoea, haemoptysis, tachycardia, & tachypnoea
209
What may be heard on ascultation in a pulmonary embolism?
Clear chest sounds/crackles on auscultation
210
What are some risk factors for pulmonary embolism?
Underlying cancer
Recent surgery
Recent pregnancy & 6 weeks postpartum
Oral contraceptive pills
211
What rule-out criteria can be used in pulmonary embolism & when is it used?
Pulmonary embolism rule-out critera (PERC) → PERC is done when there is low clinical suspicon of PE, but you want some reassurance. If you suspect a PE, then move straight to the two-level PE Wells score
212
What score must the pulomary embolism rule-out criteria be to rule out pulmonary embolism?
0
213
What is the pulmonry embolism rule-out criteria?
Age <50 years
Heart rate <100 bpm
Oxyhemoglobin saturation ≥95%
No hemoptysis
No estrogen use
No prior DVT or PE
No unilateral leg swelling
No surgery/trauma requiring hospitalization within the prior four weeks
214
What criteria is used if pulmonary embolism is suspected?
Two-level PE Wells score
≥ 5 points = PE is likely
≤ 4 points = PE is unlikely
215
What criteria are on the Two-Level Wells Score?
Clinical signs and symptoms of DVT (+3)
PE is #1 diagnosis OR equally likely (+3)
Heart rate > 100 (+1.5)
Immobilization at least 3 days OR surgery in the previous 4 weeks (+1.5)
Previous, objectively diagnosed PE or DVT (+1.5)
Hemoptysis (+1)
Malignancy w/ treatment within 6 months or palliative (+1)
216
What should be done immediately if a PE is deemed likely?
CTPA
If CTPA is delayed then give interim anticoagulation (DOAC e.g. apixaban) until the scan is performed
217
What should be considered if a PE is considered likely but a CTPA is negative?
Consider a proximal leg vein ultrasound
218
What should be considered if a PE is considered likely and a CTPA is positive?
Anticoagulation
1st line: DOAC e.g. apixaban or rivaroxaban
2nd line: LMWH
219
What should be done immediately if a PE is deemed unlikely?
Arrange a D-dimer
(if D-dimer +ve, then arrange an immediate CTPA)
220
What is the investigation of choice for pulmonary embolism if there is renal impairment?
V/Q scan if 2-level PE Wells score > 4
221
Describe D-Dimers use
D-dimers are highly sensitive but have poor specificity
222
What ECG changes are seen in pulmonary embolism?
Sinus bradycardia, S1Q3T3
223
What investigation is recommended for all patients with suspected pulmonary embolism to exclude other causes?
CXR, typically normal in PE but can present with a wedge-shaped opacification
224
What is the first-line anticoagulation for pulmonary embolism?
DOACs (Rivaroxaban or Apixaban)
225
What is the second-line anticoagulation for pulmonary embolism?
LMWH; followed by dabigitran/edoxaban or warfarin
226
What is the management of pulmonary embolism with haemodynamic instability?
Thrombolysis
227
What should patients who have a pulmonary embolism, despite taking anticoagulation, be considered for?
An inferior vena cava filter
228
What is the length of anticoagulation continuation for pulmonary embolisms?
Provoked → 3 months
Unprovoked → 6 months
229
Which chemotherapy drugs most commonly cause drug-induced pulmonary fibrosis?
Bleomycin and busulfan
230
Which antiarrhythmic most commonly cause drug-induced pulmonary fibrosis?
Amiodarone
231
Which antibiotic most commonly causes drug-induced pulmonary fibrosis?
Nitrofurantoin
232
Which immune modulator most commonly causes drug-induced pulmonary fibrosis?
Methotrexate
233
What is idiopathic pulmonary fibrosis?
A rare, progressive, chronic fibrosis of the insterstitium of the lungs with unknown aetiology
234
Who does idiopathic pulmonary fibrosis typically affect?
The elderly
Men
235
How does idiopathic pulmonary fibrosis present?
Shortness of breath on exertion, non-productive cough with bibasal fine end-inspiratory crepitations on auscultation, & clubbing on inspection of the hands
236
What is a complication of idiopathic pulmonary fibrosis?
Pulmonary hypertension which may result in cor pulmonale over time
237
What can be the initial investigaiton for pulmonary fibrosis?
CXR, spirometry
238
What is the required/investigation of choice for pulmonary fibrosis?
High resolution CT
239
What is observed on high resolution CT in idiopathic pulmonary fibrosis?
Early = "Ground glass opacities"
Late = "Honeycombing cysts"
240
What test can be positive for idiopathic pulmonary fibrosis?
Approximately 1/3 of patients with idiopathic pulmonary fibrosis test +ve for anti-nuclear antibody
241
If a confident diagnosis of idiopathic pulmonary fibrosis cannot be made, what is the next investigation?
Biopsy
242
What is the definitive treatment for idiopathic pulmonary fibrosis?
Lung transplant
243
What is the pharmacological treatment for idiopathic pulmonary fibrosis?
Anti-fibrotic agents (e.g. pirfenidone, nintedanib) are first-line drugs that can slow the decline in FVC
244
What is the first-line non-pharmacological management for idiopathic pulmonary fibrosis?
Smoking cessation + pulmonary rehabilitation
245
What is the prognosis of pulmonary fibrosis?
Poor - most die within 5 years of diagnosis
246
What ethnicities are most commonly affected by sarcoidosis?
African and scandinavian
247
How can sarcoidosis present?
Asymptomatically, but also present with a wide range of symptoms & signs
248
How does sarcoidosis appear on CXR?
Bilateral hilar lymphadenopathy
249
What skin changes appear in sarcoidosis?
Lupus pernio & erythema nodosum
250
What conditions is sarcoidosis associated with?
Bell's palsy
Uveitis
Interstitial Lung disease
Hypercalcemia due to increased 1α-hydroxylase activity in epithelioid histiocytes
251
What is the likely diagnosis in a young adult male with one month of shortness of breath, nonproductive cough, and fatigue? The patient is hypercalcaemic and has bilateral hilar fullness on CXR
Sarcoidosis
252
What is Löfgren syndrome?
An acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia
253
What is Heerfrodt's syndrome?
A variant of sarcoidosis characterized by parotid enlargement, facial nerve palsy, and uveitis
254
What are the initial investigations for sarcoidosis?
CXR, bloods (↑ ACE, ↑ Calcium) , & lung function tests (restrictive)
255
What would sarcoidosis show on tissue biopsy?
Non-caseating granulomas
256
What is the management in asymptomatic sarcoidosis?
Monitoring
257
What is the management in symptomatic sarcoidosis?
Steroids
258
What is sarcoidosis?
A multisystem non-caseating granulomatous disorder of unknown aetiology that commonly affects the lungs & lymphatic system, but can affect any organ
259
What is the most accurate investigation for sarcoidosis?
Lymph node biopsy
260
What is tuberculosis?
An infection caused by Mycobacterium tuberculosis that commonly affects the lungs
261
What is primary tuberculosis?
Primary tuberculosis is a non-immune host exposed to Mycobacterium tuberculosis which develops a small lung lesion called Ghon focus. A Ghon focus lung lesion + hilar lymph nodes is known as a Ghon complex in tuberculosis
262
How can a Ghon complex develop?
Ghon focus lung lesions (tuberculosis) usually heal in immunocompetent individuals
It can develop into disseminated miliary tuberculosis in immunocompromised individuals
263
What is secondary tuberculosis?
When the infection is reactivated
Typically due to the host becoming immunocomprimised:
- JAK inhibitors (tofacitinib)
- TNF-alpha inhibitors
- Chronic steroid use
- Chemotherapy
264
What other regions can be affected in extra-pulmonary tuberculosis?
Lymphatic (scrofula in cervical lymph nodes)
Skeletal TB (Pott's disease of the spine)
TB meningitis
Miliary TB
Genitourinary TB (renal & pelvis affected)
265
What is the most serious complication of tuberuclosis?
Tuberculosis meningitis
266
What is a ghon focus?
A caseating granuloma located near the pleura in the middle or lower lobes of the lung
267
What is miliary tuberculosis?
Disseminated infection throughout the body which can result in granuloma formation in the spleen, liver, adrenal gland and meninges
268
Which type of granuloma is characteristic of tuberculosis and fungal infections?
Caseating granulomas
269
What are some risk factors for tuberculosis?
Living in areas with high TB prevalence (e.g. South-East Asia, Africa, Western Pacific)
Patients with HIV are x25 more likely to develop active tuberculosis
Patients who are immunocomprimised
270
What pneumoconiosis has an increased risk for tuberculosis?
Silicosis
271
What investigation is done to screen for latent tuberculosis?
Mantoux test - it is injected intradermally and results are observed 2-3 days later
≤ 5mm = Negative → can give BCG vaccine
≥ 5mm = Positive → do not give BCG (previous/latent infection or already vaccinated)
272
What investigation is done to screen for latent tuberculosis in patients who may produce false negative tests?
Interferon-γ release assay
273
What are the initial investigations for tuberculosis?
CXR, x3 sputum smears
274
What is the most important investigation for tuberculosis?
Sputum culture MC&S
275
How does tuberculosis appear on CXR?
Upper lobe cavitation & bilateral hilar lymphadenopathy
276
What are the four drugs used in active tuberculosis management?
Rifampicin - 6 months
Isoniazid (take with pyridoxine (vit B6)) - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months
277
What is the management of latent tuberculosis?
3 months of isoniazid (taken with pyridoxine) + rifampicin
OR
6 months of isoniazid (taken with pyridoxine)
278
What is the management of multidrug-resistant tuberuclosis (MDR-TB)?
~18-20 months of Rifampicin, Isoniazid (taken with pyridoxine), Pyranzinamide, Ethambutol
279
When might directly observed therapy be indicated for tuberculosis patients?
In homeless, patients with poor compliance, and prisoners
280
What vaccine is given to prevent tuberculosis?
BCG
281
What is the notable side effect of rifampin?
Red/orange bodily secretions/urine
282
What is the notable side effect of isoniazid?
Peripheral neuropathy (prevented with pyridozine Vitamin B6), ataxia, and paresthesias
283
What is the notable side effect of pyrazinamide?
Hyperuricaemia causing gout
284
What is the notable side effect of ethambutol?
Optic neuritis (loss of visual acuity and red-green colorblindness)
285
What tuberculosis drug is most commonly associated with liver injury?
Isoniazid
UK MLA
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