1
Q
Acute Respiratory Distress Syndrome (ARDS) pathophysiology
A
Injury to the alveolar-capillary membrane → increased permeability.
Protein-rich fluid leaks into alveoli → impaired gas exchange and reduced lung compliance.
Results in acute, non-cardiogenic pulmonary oedema and refractory hypoxaemia.
2
Q
Causes Acute Respiratory Distress Syndrome (ARDS)
A
Sepsis
Severe pneumonia
Major trauma (especially chest trauma)
Acute pancreatitis
Transfusion-related acute lung injury (TRALI)
3
Q
Berlin Definition):
A
Acute Respiratory Distress Syndrome (ARDS)
Acute onset (within 1 week of insult)
Bilateral opacities on chest imaging (CXR/CT)
Hypoxaemia (e.g. PaO₂/FiO₂ < 300 mmHg) despite oxygen therapy
Not explained by cardiac failure or fluid overload
Normal pulmonary capillary wedge pressure (<18 mmHg) supports non-cardiogenic cause
4
Q
Management Acute Respiratory Distress Syndrome (ARDS)
A
Supportive ICU care, prone positioning
Treat underlying cause (e.g. sepsis, pneumonia)
Mechanical ventilation
Low tidal volume (6 mL/kg ideal body weight)
Maintain plateau pressure <30 cmH₂O
5
Q
Sepsis or pancreatitis → rapid hypoxaemia + bilateral infiltrates
A
think ARDS
6
Q
SERPINA1 gene mutations (e.g. PiZZ).
A
(AATD)
7
Q
Alpha-1 Antitrypsin Deficiency (AATD) Pathophysiology
A
Autosomal codominant disorder caused by SERPINA1 gene mutations (e.g. PiZZ).
Deficiency or dysfunction of alpha-1 antitrypsin, a protease inhibitor that normally protects alveolar tissues from neutrophil elastase.
Accumulation of misfolded AAT in hepatocytes → hepatotoxicity.
Lack of AAT in lungs → uncontrolled elastase activity, leading to emphysema.
8
Q
Investigations (AATD)
A
Serum AAT level – screening test (low level confirms deficiency)
Genetic testing – PiZZ most severe; PiSZ or PiMZ less severe
Spirometry – obstructive pattern (↓ FEV1/FVC)
CXR / CT / Liver ultrasound
9
Q
Management (AATD)
A
Smoking cessation, bronchodilators (e.g. LABAs, LAMAs), pulmonary rehab, vaccination
Alpha-1 antitrypsin augmentation therapy (IV) – slows lung decline in selected patients
10
Q
Young adult, non-smoker with COPD chronic cough, SOB and derange LFTs →
A
think AATD
11
Q
recurrent chest infections with family history of COPD or liver disease
A
(AATD)
12
Q
Step 1in investigations asthma
A
Eosino above range
Feno >_ 50
13
Q
Step 2 in investigations asthma
A
Spiromeyry + bronchodilator reversibility
Fev1 increase >_ 12% and 200ml
Fev1 increase >_ 10% of predicted
14
Q
Step 3in investigations asthma
A
Pef monitoring 2 weeks
Best of 3 readings bd
Pef variability >_ 20 %
15
Q
Adults (17+)
1st line: inv asthma
A
:
FeNO ≥ 50 ppb → confirms asthma
Or eosinophils > reference range → confirms asthma
16
Q
Children (5–16)
1st line: inv asthma
A
FeNO ≥ 35 ppb → confirms asthma
17
Q
Children (5–16)
2nd line: inv asthma
A
2nd line: If asthma not confirmed by FeNO or eosinophils:
Spirometry with bronchodilator reversibility: FEV₁ increase ≥12% → confirms asthma
18
Q
Spirometry in asthma
A
Obstructive: FEV₁/FVC < 70%
Reversibility: ≥12% improvement post-bronchodilator (and ≥200mL in adults)
19
Q
FeNO
In lung inflammation, FeNO (fraction of exhaled nitric oxide) is elevated
A
50 ppb in adults, >35 ppb in children = positive
20
Q
Chronic Asthma Management (2024 Guidelines)
Step 1 – New Diagnosis
A
Commence AIR therapy
PRN Low-dose inhaled corticosteroid (ICS) / long-acting beta agonists (LABA)
e.g. budesonide / formoterol used only as-needed -
21
Q
Step 2 – Uncontrolled Symptoms asthma
A
Commence MART Therapy
The combination inhaler (like in AIR therapy) is with a combined ICS/LABA (budesonide / formoterol)
Start with low-dose Maintenance and Reliever Therapy (MART)
22
Q
Step 3 – Persistent Symptoms asthma
A
Moderate-dose MART (increase ICS dose)
23
Q
Step 4 – Still Uncontrolled asthma
A
Check FeNO & eosinophils:
If raised → specialist referral
If normal 9-12 weeks trial of
LTRA (e.g. montelukast)
or LAMA (e.g. glycopyrronium)
24
Q
Step 5 – Refractory asthma
A
Trial switch between LTRA and LAMA
If still uncontrolled → specialist referral
25
Management: Switching from Older Regimens to New Guidelines asthma
SABA-only users → switch to AIR therapy
Uncontrolled on low-dose ICS or ICS/LABA → switch to low-dose MART
Moderate-dose ICS-based treatment → switch to moderate-dose MART
26
Indicators of Uncontrolled Asthma
Exacerbation requiring oral steroids
Frequent reliever use (≥3 days/week)
Nocturnal symptoms ≥1/week
27
Inhaler Dose Equivalence
Low dose = 400 mcg budesonide
Medium dose = 400–800 mcg
High dose = >800 mcg
28
Acute Asthma Exacerbation moderate
50–75% Normal < 110 bpm < 25 breaths/min > 92% Nil
29
Severe Acute Asthma Exacerbation
33–50% Can't complete sentences > 110 bpm > 25 breaths/min > 92% Nil
30
Life-threatening Acute Asthma Exacerbation
< 33% Bradycardia or arrhythmia Any rate < 92% Silent chest, cyanosis, hypotension, fatigue, poor effort
31
Near-fatal Acute Asthma Exacerbation
Hypercapnia (↑PaCO₂), intubation required
32
Emergency Management asthma
A→E approach, oxygen to maintain sats 94–98%
Nebulised salbutamol (± ipratropium)
Oral prednisolone 40–50mg or IV hydrocortisone
If life-threatening: IV magnesium sulphate (1.2–2g over 20 min), back-to-back salbutamol nebs
O SHIT ME!
Oxygen, Salbutamol, Hydrocortisone, Ipratropium, Theophyline, Magnesium, ET intubation
33
Occupational Asthma exposure
Common exposures: isocyanates (spray paint), baking (flour), working w/ animals, welding, lab work
34
Occupational Asthma diagnosis
Diagnosis: serial PEFR + specialist referral
35
Adult with wheeze + atopy →
Asthma
36
Young adult with cough and wheeze triggered by exercise → initiate
Air
37
Acute asthma with silent chest, hypotension →
life-threatening → A–E + nebs + IV magnesium
38
adult-onset wheeze with improvement on weekends/holidays and noticeably worse at work
Occupational Asthma
refer for serial PEFR
39
SOB and desaturation 48-72 hours post-op.
Atelectasis Common post-op complication
consider PE too)
40
Management Atelectasis
Prevention: Early mobilisation, deep breathing exercises, chest physiotherapy
Treatment: Treat cause, supplemental oxygen, positive pressure ventilation if severe
41
Post-op patient, 48 hours after abdominal surgery, with SOB and hypoxia →
think atelectasis.
42
irreversible dilation of bronchi.
Bronchiectasis
43
Post-infective Bronchiectasis causes
TB, pneumonia, measles, pertussis
44
Genetic causesBronchiectasis
Cystic fibrosis, Kartagener’s (PCD + situs inversus + sinusitis)
45
Immunodeficiency causes Bronchiectasis
IgA deficiency, hypogammaglobulinaemia
46
Autoimmune causes of Bronchiectasis
Rheumatoid arthritis
47
Chronic lung disease causesBronchiectasis
Severe/poorly controlled asthma/COPD
48
Yellow nail syndrome
Thick yellow nails + pleural effusions + bronchiectasis
49
Investigations Bronchiectasis
Sputum culture: Identify colonising organisms (e.g. H. influenzae, pseudomonas)
Spirometry: Obstructive pattern (FEV1/FVC < 0.7)
Chest X-ray: ‘Tramlines’ (parallel thickened bronchial walls)
Diagnostic investigation of choice: HRCT chest (gold standard):
Signet ring sign – dilated bronchus adjacent to artery
Cylindrical/varicose/cystic bronchial dilatation
50
Conservative mx Bronchiectasis
Chest physiotherapy: Postural drainage, sputum clearance
Pulmonary rehabilitation
51
Medical mx Bronchiectasis
Vaccinations: Annual flu + pneumococcal
Bronchodilators: LABA (e.g. formoterol) if SOB
LTOT: Consider if PaO2 < 7.3 or SpO2 < 88%
Antibiotics:
Prophylaxis if ≥3 exacerbations/year: Azithromycin or erythromycin
Pseudomonas colonisation: Inhaled colistin
52
LTOT: Consider if
PaO2 < 7.3 or SpO2 < 88%
53
Pseudomonas colonisation
Inhaled colistin
54
Common Pathogens
Infective Exacerbation of Bronchiectasis
H. influenzae (most common)
Pseudomonas, Klebsiella, Strep pneumoniae
55
Mx Infective Exacerbation of Bronchiectasis
Send sputum sample (ideally before ABx, but do not delay treatment a/w result)
PO antibiotics (14 days), ideally according to sensitivities. If nil prior, NICE suggests:
Amoxicillin, clarithromycin, doxycycline
High risk/severe: co-amoxiclav or levofloxacin
Admit for IV ABx if hypoxic, febrile >38°C, or confused
56
Cystic Fibrosis (CF) aetiology
Autosomal recessive, ΔF508 mutation in CFTR gene on chromosome 7
57
Diagnosis Cystic Fibrosis (CF)
Sweat test: Chloride > 60 mmol/L diagnostic
Genetic testing
Newborn screening: Immunoreactive trypsin test
58
Management Cystic Fibrosis (CF)
Multidisciplinary MDT care
High calorie/fat diet
Orkambi (lumacaftor/ivacaftor) – if homozygous ΔF508
59
Orkambi
lumacaftor/ivacaftor) – if homozygous ΔF508
Cf
60
Primary Ciliary Dyskinesia (PCD)Aetiology
Autosomal recessive – dynein arm defect impairs ciliary motion
61
Clinical Features Primary Ciliary Dyskinesia (PCD)
Bronchiectasis
Situs inversus (± dextrocardia) → Kartagener's syndrome
Infertility – impaired sperm motility
Chronic sinusitis, otitis media
62
Recurrent chest infections + productive cough + coarse crepitations =
Bronchiectasis
63
Young adult w/ chronic cough + chronic sinusitis + situs inversus =
Kartagener's
64
Bronchiectasis + nasal polyps + pancreatic symptoms =
Cystic Fibrosis
65
Persistent colonisation with pseudomonas
Consider colistin
66
contraindication to lung transplant in CF
Burkholderia cepacia
67
COPD =
chronic bronchitis (cough > 3 months in 2 consecutive years) + emphysema (alveolar destruction).
68
Spirometry in copd
Fev1/FVC < 0.7 post-bronchodilator
Fev1% predicted (severity):
80% = Mild
50–79% = Moderate
30–49% = Severe
<30% = Very severe
69
Fev1% predicted (severity):copd
80% = Mild
50–79% = Moderate
30–49% = Severe
<30% = Very severe
70
Other investigations in copd
FBC: may show polycythaemia, eosinophilia
CXR: hyperinflation, flat diaphragm
BMI: for BODE index
Consider eosinophil count for ICS responsiveness
71
CAT score
0-10 group a any bronchodilater
>10 group b laba+lama
72
Management copd
A - Mild symptoms, ≤1 exacerbation - Any bronchodilator
B - Severe symptoms, ≤1 exacerbation - LAMA/LABA
Examples: Bevespi Aerosphere, Anoro Elipta, Stiolto Respimat.
E - ≥2 exacerbations OR 1 leading to hospitalisation - LAMA/LABA - add ICS if eos > 300
Example: trimbow = LAMA/LABA/ICS
73
trimbow
LAMA/LABA/ICS
74
Avoid ICS in copd if:
Recurrent pneumonia
Eosinophils < 100
75
Non-Pharmacological Management copd
Smoking cessation
Vaccination: annual influenza + one-off pneumococcal
Pulmonary rehabilitation (if mMRC ≥3)
Weight management
76
LTOT (Long-Term Oxygen Therapy)
Indications for ABG assessment:
Fev1 < 49%
Peripheral oedema, polycythaemia
SpO2 < 92% on air
77
LTOT criteria:
PaO2 < 7.3 kPa
PaO2 7.3–8.0 kPa with one or more of:
Cor pulmonale
Polycythaemia
Pulmonary hypertension
78
Ltot Contraindicated in
ongoing smokers
79
Acute Exacerbation of COPD (AECOPD)
📉 Causes:
Bacterial: H. influenzae (most common), S. pneumoniae, M. catarrhalis
Viral: rhinovirus
80
Acute Exacerbation of COPD (AECOPD) mx
Prednisolone 30 mg OD for 5 days
Antibiotics if:
Increased sputum purulence
Clinical signs of pneumonia
First-line: Amoxicillin / Clarithromycin / Doxycycline
81
NIV (Non-invasive Ventilation)
Indications:
Type 2 RF with acidosis (pH < 7.35 + CO₂ > 6)
NMD, chest wall disease, OSA with RF
Cardiogenic pulmonary oedema unresponsive to CPAP
82
📦 Additional Therapies copdrefractory cases)
PO theophylline
83
severe COPD + chronic bronchitis + frequent exacerbations) 📦 Additional Therapies
Roflumilast
84
prophylaxis (if non-smoker, no bronchiectasis, no QTc prolongation) copd
Azithromycin
85
for cor pulmonale 📦 Additional Therapies
Diuretics
86
Smoker > 35 with chronic cough/dyspnoea →
suspect COPD
87
Fev1/FVC < 0.7 post-bronchodilator
Copd
88
Management copdEosinophils > 300 =
ICS indication
89
Exacerbation + purulent sputum =
antibiotics + prednisolone
90
Red Flags & Referral Criteria (NICE 2WW)
📍 2WW Referral RESP
Any age with:
Chest X-ray suggestive of lung cancer
Age ≥ 40 with:
Unexplained haemoptysis
91
Urgent Chest X-Ray (within 2 weeks)
Age ≥ 40 with 2 or more unexplained symptoms (1 if ever smoked):
Cough
Breathlessness
Fatigue
Chest pain
Weight loss
Loss of appetite
92
Investigations lung ca
CXR – may be normal (10% of cases)
CT Chest – diagnostic test of choice
Bronchoscopy ± EBUS – for biopsy
PET scan – used in NSCLC to determine eligibility for curative treatment
93
Small Cell Lung Cancer (SCLC) origin
APUD cells (Amine Precursor Uptake Decarboxylase)
Highly aggressive, early metastasis
Usually central on imaging
94
Paraneoplastic Syndromes: sclc
SIADH → hyponatraemia
ACTH → Cushing’s syndrome, hypokalaemic alkalosis
Lambert-Eaton myasthenic syndrome - Antibodies vs voltage gated calcium channels —> presenting with proximal weakness
95
Management sclc
Chemoradiotherapy (mainstay)
Surgery only if T1-2a N0 M0
96
Squamous Cell Carcinoma
Paraneoplastic
PTHrP → hypercalcaemia
Hypertrophic pulmonary osteoarthropathy (HPOA) → clubbing, painful wrists/ankles
TSH → hyperthyroidism
97
Most common type of lung cancer in non-smokers
Adenocarcinoma
Peripheral location
98
Paraneoplastic features: Adenocarcinoma
HPOA
Gynaecomastia
99
Large Cell Carcinoma
Poorly differentiated, poor prognosis
Paraneoplastic features:
β-hCG → may cause gynaecomastia
100
Exudate with low ph
Empyema
101
Carcinoid Tumour origin
Bronchial carcinoid (1% of cases)
Cell of origin: APUD (like SCLC)
Bronchoscopy shows cherry red ball
Carcinoid syndrome rare, more common with liver metastasis
102
Bronchoscopy shows cherry red ball
Carcinoid Tumour
103
Superior Vena Cava Obstruction (SVCO)
Oncological emergency
Common causes
SCLC, lymphoma
104
Pemberton’s sign
arm elevation worsens symptoms
Superior Vena Cava Obstruction (SVCO)
105
Superior Vena Cava Obstruction (SVCO) mx
Dexamethasone
Chemotherapy or radiotherapy
Balloon venoplasty/stenting
106
SIADH with lung mass
Sclc
107
Cushing’s syndrome + lung lesion
ACTH-producing SCLC
108
β-hCG and lung tumour →
Large cell
109
Cherry red ball on bronchoscopy →
Carcinoid
110
Clubbing + hypercalcaemia →
Squamous cell
111
Gynaecomastia + lung lesion in non-smoker →
Adenocarcinoma
112
Facial plethora, SOB, raised JVP
SVCO → Dexamethasone, stenting
113
low TLCO suggests
impaired gas exchange.
114
Normal fev1
Normal: > 80% of predicted
115
FEV1/FVC Ratio
Normal:
: > 0.7
116
Restrictive Airway Disease
Causes
Pulmonary fibrosis
Asbestosis
Sarcoidosis
ARDS
Kyphoscoliosis
Neuromuscular disorders (e.g. MND)
117
KCO
TLCO corrected for alveolar volume.
118
Causes of Low TLCO
Pulmonary fibrosis
Pneumonia
Pulmonary embolism
Pulmonary oedema
Emphysema
Anaemia
119
Causes of High TLCO
Asthma
Pulmonary haemorrhage (e.g. GPA)
Polycythaemia
Hyperdynamic states (e.g. pregnancy, hyperthyroidism)
Left-to-right cardiac shunt
120
Obstructive (Fev1/FVC <0.7) + reversible =
Asthma
121
Obstructive (Fev1/FVC <0.7) + non-reversible
Copd
122
Restrictive + low TLCO =
Pulmonary fibrosis
123
Causes & Risk Factors osa
Obesity
Enlarged tonsils/adenoids
Macroglossia
Small jaw (retrognathia)
Nasal obstruction (e.g. deviated septum)
124
Investigations osa
Polysomnography (sleep study): Gold standard test, provides Apnoea-Hypopnoea Index (AHI) to grade severity
Epworth Sleepiness Scale (ESS): Questionnaire assessing subjective daytime sleepiness
124
DVLA Advice osa
Patients must inform the DVLA if:
OSA is associated with excessive daytime sleepiness and
They drive for work or operate heavy vehicles
125
Morning headaches + nocturia are subtle clues
Osa
126
Management osa
Lifestyle measures: Weight loss, avoid alcohol and sedatives before bed
1st Line: Continuous Positive Airway Pressure (CPAP)
Indicated for moderate or severe OSA (AHI > 15, or AHI 5–14 with symptoms)
Oral devices: Mandibular advancement splints may help in mild OSA or if CPAP not tolerated
Surgical options: Rare; tonsillectomy/adenoidectomy if anatomical cause
126
Investigations Pleural Effusion
All patients should have CXR (see below)
US guided pleural tap is recommended
CT can be considered for the diagnosis of exudative causes
126
Classification: Transudate vs Exudate
Transudate < 30 g/L
127
Exudates =
Excess protein = Inflammation/Infection”
128
Causes transudate
Heart failure, liver failure (cirrhosis), nephrotic syndrome, hypothyroidism, Meig’s syndrome
128
Light’s Criteria
Use when pleural fluid protein is 25–35 g/L.
Effusion is exudative if ANY of the following are true:
Pleural fluid LDH > 2/3 upper limit of serum LDH
Pleural fluid/serum LDH ratio > 0.6
Pleural fluid/serum protein ratio > 0.5
128
EmpyemaSuspect if
Turbid/cloudy fluid
pH < 7.2
Low glucose
Positive culture/gram stain
128
Management Empyema
Chest drain
Antibiotics
129
Unilateral exudate + weight loss
suspect malignancy.
130
Low pH (<7.2), turbid fluid, pneumonia
Empyema
131
Primary Pneumothorax
Often occurs
young, tall, thin patients
132
Secondary Pneumothorax
Occurs in the context of:
COPD / asthma
Bronchiectasis (inc. CF)
Tuberculosis
Interstitial lung disease
Older smokers (>50 years)
133
1st LINE inv pneumothorax
PA CXR
134
Gold std inv pneumothorax
If further evaluation is required – CT thorax – gold standard
135
Classification pneumothorax
Small < 2 cm from lung edge to chest wall at hilar level
Large > 2 cm at hilar level
Tension One-way valve → ↑ intrathoracic pressure → shock
136
Asymptomatic (any size) pneumothorax management
Conservative + follow-up
137
Symptomatic + high-risk (e.g. secondary pneumothorax, >50, hypoxia)
Chest drain
138
Symptomatic + no high-risk characteristics pneumothorax
Needle aspiration or procedure avoidance
139
General guidelines pneumothorax management
High-flow O2 (15L/min via NRBM) – unless contraindicated (e.g. COPD)
Avoid scuba diving permanently unless pleurectomy + clearance
Follow-up to confirm full resolution
140
Procedure Details
Aspiration pneumothorax
16–18G cannula
Less invasive and may be preferred in low-risk cases
141
Chest Drain details
5th intercostal space, mid-axillary line
Remove when: no bubbling, patient coughing, or CXR confirms resolution
142
Chest Drain contraindications
Relative contraindications: INR > 1.3, platelets < 75, pleural adhesions, pulmonary bullae
143
Complications chest Drain
Re-expansion pulmonary oedema
If SOB/cough after drain → clamp and repeat CXR
144
Tension Pneumothorax
Immediate Management
Needle decompression:
Large bore 14–16G needle
Site options:
2nd ICS mid-clavicular line (traditional)
4th–5th ICS mid-axillary line (modern preference)
Follow with chest drain insertion.
145
Young male, tall, thin, acute pleuritic pain →
primary pneumothorax.
146
Sudden deterioration, hypotension, tracheal deviation →
tension pneumothorax.
147
COPD patient + SOB + hyperresonant percussion →
secondary pneumothorax.
Chest drain
148
Cough/SOB after chest drain →
re-expansion oedema → clamp and re-image.
149
Baseline Tests pe
ECG: Sinus tachycardia (most common), S1Q3T3, RAD, RBBB
CXR: Usually normal or nonspecific; rules out other causes
FBC, U&Es, clotting, ABG
150
Imaging pe
CTPA: 1st line diagnostic tool
V/Q Scan: 1st line in pregnancy or if renal impairment and normal CXR
151
Two Level Wells Score
Clinical Feature
Clinical signs of DVT 3
PE most likely diagnosis 3
HR > 100 1.5
Immobilisation > 3 days or surgery < 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (treated in last 6 months or palliative) 1
152
Wells ≤ 4 =
PE unlikely → check D-dimer
> 4 = PE likely → immediate CTPA (or NOAC if delay)
153
Management pe
1st Line: NOAC (e.g. apixaban/rivaroxaban)
2nd Line: LMWH, warfarin or dabigatran
Renal impairment (eGFR < 15): Warfarin (with LMWH bridging)
Antiphospholipid syndrome: Warfarin (with LMWH bridging)
154
Duration
Provoked PE:
3 months
Unprovoked PE: 6 months and reassess
155
Thrombolysis
Indications:
Pe
Haemodynamic instability (SBP < 90)
Consider in submassive PE with RV dysfunction or elevated troponin
Agents: alteplase, streptokinase
156
If recurrent PE despite anticoagulation
IVC Filters
157
PE in Pregnancy
InvestigationsBaseline
ECG + CXR for all
158
PE in Pregnancy
Investigations
If signs of DVT:
USS legs → treat if positive, no further imaging needed
Avoids need for CTPA/V/Q adverse effects
159
PE in Pregnancy
Investigations
If no DVT signs:
CXR normal: V/Q scan preferable
CXR abnormal: CTPA preferable
Advise patients of the following risks, and involve them in the decision making where feasible:
Compared with CTPA, V/Q scanning may carry a very small increased risk of childhood cancer
CTPA is associated with a higher risk of maternal breast cancer
Avoid D-dimer
160
Treatment pregnancy pe
LMWH is 1st line
Continue until at least 6 weeks post-partum (min. total duration 3 months)
161
Sudden SOB + pleuritic chest pain + tachycardia = susp
Pe
162
Wells > 4 or D-dimer positive →
CTPA
163
Massive PE (SBP < 90) =
thrombolyse
164
Pregnancy + leg swelling →
USS leg first
165
CHARTSS
Upper zone causes: CHARTSS — Coal worker's, Hypersensitivity pneumonitis, Ankylosing spondylitis, Radiation, Tb, Silicosis, Sarcoidosis.
166
ACID
Lower zone causes: ACID — Asbestosis, Connective tissue disease, Idiopathic PF, Drugs.
167
Gold standard for diagnosis Pulmonary Fibrosis
HRCT: Gold standard for diagnosis (honeycombing, ground-glass)
168
↑ ACE/hypercalcaemia
sarcoidosis
169
Management
IPF
Nintedanib or pirfenidone if FVC 50–80% (NICE CG163)
Pulmonary rehab, LTOT if needed
Lung transplant (select cases)
Supportive
Smoking cessation
Vaccinations (influenza, pneumococcal)
Oxygen therapy for hypoxaemia
170
Nintedanib or pirfenidone
Ipf
171
Drugs causing Pulmonary Fibrosis
amiodarone, bleomycin, methotrexate, nitrofurantoin
172
Hypersensitivity Pneumonitis
Acute phase:
Type 3 hypersensitivity reaction (immune complex deposition)
Symptoms occur 4-8 hours post exposure - shortness of breath, cough, fever
173
Hypersensitivity Pneumonitis
Chronic phase:
Type 4 hypersensitivity reaction (T cell mediated)
Progressive symptoms which develop after weeks to months of repeated exposure - shortness of breath, weight loss, productive cough
174
Causes Hypersensitivity Pneumonitis
Bird fancier’s (avian proteins)
Farmer’s lung (saccharopolyspora)
Mushroom workers
175
HRCT: Ground-glass, mosaic attenuation
Hypersensitivity Pneumonitis
176
Hypersensitivity Pneumonitis mx
Steroids, avoid allergen
177
CXR: Eggshell calcification of hilar nodes
Silicosis
Inhalation of silica particles (mining, sandblasting)
Upper zone fibrosis
178
African/Caribbean young adults
Symptoms: Cough, SOB, erythema nodosum, polyarthralgia
Sarcoidosis
179
Bloods in sarcoidosis
Bloods: ↑ ACE, ↑ calcium, ↑ ESR
180
Sarcoidosis mx
Steroids if:
1. Symptomatic and infiltrates on CXR (in addition to BHL)
2. Hypercalcaemia
3. Eye, heart or neurological involvement
181
Mesothelioma strongly linked to
blue asbestos
182
Older male with SOB, clubbing, bibasal creps
Ipf
183
Bird owner with dry cough + HRCT changes →
Hypersensitivity pneumonitis
184
Young African-Caribbean with BHL + ↑ calcium/ACE
Sarcoidosis
185
Ex-miner with upper zone fibrosis + eggshell calcification →
Silicosis
186
Ex-shipbuilder with pleural thickening or effusion →
Mesothelioma
187
Rust-coloured sputum, rapid onset, may co-occur with HSV (cold sores).
Streptococcus pneumoniae
188
Haemophilus influenzae Common in
patients with COPD or bronchiectasis
189
Often occurs following an influenza infection.
Staphylococcus aureus
190
Seen in alcoholics; red ‘currant jelly’ sputum; can lead to lung abscess.
Klebsiella pneumoniae
191
Investigations Pneumonia
CXR
Sputum culture, blood culture if CURB ≥ 2.
Mycoplasma/Legionella PCR or serology if suspected.
Repeat CXR at 6 weeks if: Persistent symptoms, smoker or age >50
192
CURB-65 Severity Score
C – Confusion AMTS < 8
U – Urea > 7 mmol/L
R – Respiratory rate ≥ 30 breaths per min
B – Blood pressure < 90 systolic or ≤ 60 diastolic
65 - Age ≥ 65 years
193
Low severity (CURB 0–1 or CRB65 = 0) mx
1st line: Amoxicillin 500mg TDS 5 days
Penicillin allergy: Clarithromycin or doxycycline
194
Moderate severity (CURB 2 or CRB65 = 1-2)mx
Amoxicillin + Clarithromycin
Penicillin allergy: Doxycycline or clarithromycin
195
High severity (CURB or CRB65 ≥ 3)
IV Co-amoxiclav + Clarithromycin
Penicillin allergy: Levofloxacin
196
Epidemics occur roughly every 4 years —
Mycoplasma pneumoniae
197
Mycoplasma pneumoniae clinical Features
Gradual onset
Typically affects younger patients
Flu-like prodrome followed by dry cough
Sore throat (URTI symptoms)
Chest often clear on auscultation
198
Complications Mycoplasma pneumoniae
Cold autoimmune haemolytic anaemia: cold agglutinins
Erythema multiforme: target lesions on skin
Bullous myringitis: vesicles on tympanic membrane
Myocarditis
Neurological: meningoencephalitis, Guillain-Barré (rare)
199
Management Mycoplasma pneumoniae
Resistant to β-lactams (lacks cell wall)
1st line: Doxycycline or Clarithromycin
Alternative: Erythromycin (in pregnancy)
200
recent use of air-con/holidays etc. Pneumonia
: Legionella colonises water tanks – therefore MCQs often describe a recent use of air-con/holidays etc.
201
Diagnosis Legionella pneumophila
Urinary Legionella antigen
PCR or culture of sputum or BAL
202
Management 1st line legionella
1st line: Macrolides (clarithromycin, azithromycin, erythromycin)
Alternative: Fluoroquinolones (levofloxacin, ciprofloxacin)
203
Psittacosis (Ornithosis) causative
Chlamydia psittaci – intracellular gram-negative bacterium
204
Hepatosplenomegaly
Pulse-temperature dissociation:
Psittacosis (Ornithosis)
205
Investigations Psittacosis (Ornithosis)
Bloods: raised LFTs, leukopenia
Diagnosis: Serology (complement fixation, microimmunofluorescence)
206
Management Psittacosis (Ornithosis)
1st line: Doxycycline
2nd line: Macrolides (if contraindicated or pregnant)
207
Pneumocystis jiroveci (PJP)
HIV patients (CD4 < 200), dry cough, dyspnoea
CXR: Bilateral infiltrates ± pneumothorax
208
Pneumocystis jiroveci (PJP) inv
BAL with silver stain
209
Pneumocystis jiroveci (PJP) mx
Co-trimoxazole + steroids if PaO2 < 9.3
210
COVID-19 Pneumonitis mx
Dexamethasone, Remdesivir, IL-6 inhibitors, VTE prophylaxis
211
Haemoptysis, cough
Imaging: rounded opacity with crescent sign
Aspergilloma
212
ABPA (Allergic bronchopulmonary aspergillosis) mx
1st line: Steroids, 2nd line: Itraconazole
213
Viral LRTI in infants <2 years (RSV)
Bronchiolitis
214
Diagnosis Bronchiolitis
NPA (immunofluorescence)
215
Rust-coloured sputum →
Strep pneumoniae
216
Post-influenza pneumonia →
Staph
217
Pneumonia + bird contact + hepatosplenomegaly
Psittacosis
218
Dry cough + flu prodrome + target lesions →
Mycoplasma
219
Air con + confusion + hyponatraemia →
Legionella
220
HIV + dry cough + clear auscultation →
Pjp
221
Cavitating pneumonia in alcoholic →
Kleb
222
HIV + bilateral infiltrates + pneumothorax
Pjp
223
First-line support for all smokers
behavioural therapy and pharmacological aids.
224
Nicotine Replacement Therapy (NRT) mechanism
Provides controlled nicotine doses to reduce withdrawal symptoms.
Combination (e.g. patch + short-acting oral form) more effective than monotherapy
225
Varenicline
Mechanism:
Partial agonist at nicotinic acetylcholine receptors → reduces cravings and withdrawal symptoms
Effect: Also blocks nicotine binding, reducing rewarding effects of smoking
226
Varenicline contraindications
History of depression or suicidal ideation
Pregnancy or breastfeeding
227
Bupropion
Mechanism:
Nicotinic receptor antagonist
Dopamine and noradrenaline reuptake inhibitor
228
Adverse effects: Bupropion
Risk of seizures (~1 in 1000)
Insomnia, dry mouth
229
Contraindications Bupropion
Epilepsy or seizures
Pregnancy or breastfeeding
230
Patient with epilepsy → smoker avoid which cessation method
avoid bupropion
231
Pregnant woman seeking cessation
avoid varenicline and bupropion, consider NRT
232
Best success rates: smoking cessation
Varenicline > Bupropion > NRT monotherapy
233
safe in adolescents ≥12 years
Smoking cessation
NRT
234
umeclidinium / vilanterol inhaler
Laba + lama
235
cardiac conduction abnormality, when combined with restrictive lung disease in a young man, strongly suggests
Ankylosing spondylitis
236
extrinsic allergic alveolitis (EAA), also known as
Hypersensitivity Pneumonitis
237
differentiates hypersensitivity pneumonitis from occupational asthma
The presence of systemic symptoms (fever, malaise) and delayed onset after exposure
238
criteria for long-term prophylactic antibiotic therapy in cystic Fibrosis
≥3 infective exacerbations in a year,
239
Niv in asthma
can worsen air trapping and cause barotrauma.
240
Kulchitsky cells
Carcinoid tumours are neuroendocrine tumours that typically arise from Kulchitsky cells in the bronchial mucosa
241
Complications of HIV
Bilateral infiltrates +/- pneumothorax.
Pjp
MSRA
flashcards
Decks in class (27)
# Cards
-
MEDICINE228
-
Antibiotics31
-
Ent149
-
Psychiatry59
-
Contraception49
-
Gynae95
-
Ortho1
-
Cardio304
-
Resp120
-
Derma278
-
Ophthal180
-
Endocrine322
-
Metabolic58
-
Gastro343
-
Surgery168
-
Infectious Diseases269
-
Hematology242
-
Rheumat + Musculoskeletal497
-
Rheumat + Musculoskeletal 264
-
Pediatrics389
-
Pharma254
-
Psychiatry168
-
Respiratory247
-
Uro101
-
Renal175
-
Obgyn340
-
Neuro269
