Respiratory

Question 1

What is Maintenance and Reliever Therapy? (MART)

Answer 1

Maintenance and reliever therapy (MART)

• A form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required

(example, formoterol)

Question 2

What is the stepwise approach for management of asthma?

Answer 2

Newly diagnosed Asthma:

1. Short-acting beta agonist (SABA)

Not controlled on previous step
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking:

2. SABA + low-dose inhaled corticosteroid (ICS)
3. SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
4. SABA + low-dose ICS + long-acting beta agonist (LABA)
   Continue LTRA depending on patient’s response to LTRA
5. SABA +/- LTRA
   Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS
6. SABA +/- LTRA + medium-dose ICS MART

OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA

7. SABA +/- LTRA + one of the following options:
   - Increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART)
   - A trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline)
   - Seeking advice from a healthcare professional with expertise in asthma

Question 3

What are the features of COPD?

Answer 3

COPD is an umbrella term encompassing the older terms chronic bronchitis and emphysema. In the vast majority of cases, COPD is caused by smoking. Some patients with more mild disease may just need to use a bronchodilator occasionally whereas other patients may have several hospital admissions a year secondary to infective exacerbations.

Features:
- Cough: often productive
- Dyspnoea
- Wheeze
- In severe cases, right-sided heart failure may develop resulting in peripheral oedema

Question 4

What investigations are performed in suspected COPD?

Answer 4

The following investigations are recommended in patients with suspected COPD:

• Post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%

Chest x-ray:
- hyperinflation
- bullae: if large, may sometimes mimic a pneumothorax
- flat hemidiaphragm
- also important to exclude lung cancer

Question 5

What are some causes of white shadowing on chest x ray?

Answer 5

• Consolidation
• Pleural effusion
• Collapse
• Pneumonectomy
• Specific lesions e.g. tumours
• Fluid e.g. pulmonary oedema

Question 6

What are the components of Sepsis Six?

Answer 6

The Sepsis Six consists of three diagnostic and three therapeutic steps – all to be delivered within one hour of the initial diagnosis of sepsis:

3 In:
- Titrate OXYGEN to a saturation target of 94%
- Administer empirical intravenous ANTIBIOTICS
- Start intravenous FLUID resuscitation

3 Out:
- Commence accurate URINE OUTPUT measurement.
- Take BLOOD CULTURES and consider source control
- Measure serial serum LACTATE

Question 7

What are the components of CURB65 in assessing the severity of pneumonia?

Answer 7

C Confusion (abbreviated mental test score <= 8/10)
U urea > 7 mmol/L
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years

• consider home-based care for patients with a CURB65 score of 0 or 1 - low risk
• consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk
• consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)

Question 8

What is the management for low severity community acquired pneumonia?

Answer 8

• Amoxicillin is first-line
• if penicillin allergic then use a macrolide or tetracycline
• NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia

Question 9

What is the management of moderate and high-severity community acquired pneumonia?

Answer 9

• Dual antibiotic therapy is recommended with amoxicillin and a macrolide
• a 7-10 day course is recommended
• NICE recommend considering co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia.

Question 10

Organism causing acute exacerbation of COPD?

Answer 10

The most common bacterial organisms that cause infective exacerbations of COPD are:

• Haemophilus influenzae (most common cause)
• Streptococcus pneumoniae
• Moraxella catarrhalis

Respiratory viruses account for around 30% of exacerbations, with the human rhinovirus being the most important pathogen.

Question 11

Management for acute exacerbations of COPD?

Answer 11

NICE guidelines from 2010 recommend the following:

• Increase frequency of bronchodilator use and consider giving via a nebuliser
• Give prednisolone 30 mg daily for 5 days
• It is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’
• The BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.

Question 12

How is diagnosis of asthma made?

Answer 12

Diagnostic testing

Patients >= 17 years
- patients should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma.

• All patients should have spirometry with a bronchodilator reversibility (BDR) test.
• All patients should have a FeNO test.

FeNO: Fractional exhaled Nitric Oxide. Levels of NO correlate with airway inflammation from eosinophils.

Question 13

What are the objective tests used in diagnosing asthma?

Answer 13

Fractional exhaled Nitric Oxide (FeNO)
- in adults level of >= 40 parts per billion (ppb) is considered positive.

Spirometry
- FEV1/FVC ratio less than 70% is considered obstructive.

Reversibility testing
- in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more.

Question 14

What is Light’s criteria?

Answer 14

Light’s criteria helps to distinguish between a transudate and an exudate.

• Exudates have a protein level of >30 g/L
• Transudates have a protein level of <30 g/L

if the protein level is between 25-35 g/L, Light’s criteria should be applied. An exudate is likely if at least one of the following criteria are met:
- pleural fluid protein divided by serum protein >0.5
- pleural fluid LDH divided by serum LDH >0.6
- pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

Question 15

Type 1 respiratory failure?

Answer 15

Type 1 respiratory failure: Low pO2, no CO2 retention

Question 16

Type 2 respiratory failure?

Answer 16

Type 2 respiratory failure: Low pO2, high pCO2

(example: COPD)

Question 17

Indications for chest drain insertion?

Answer 17

A chest drain is a tube inserted into the pleural cavity which creates a one-way valve, allowing movement of air or liquid out of the cavity.

Chest drain insertion is indicated in cases of:
- Pleural effusion
- Pneumothorax not suitable for conservative management or aspiration
- Empyema
- Haemothorax
- Haemopneumothorax
- Chylothorax
- In some cases of penetrating chest wall injury in ventilated patients

Question 18

What are the borders of the safety triangle for safe insertion of a chest drain?

Answer 18

The triangle of safety actually has four sides involving:

• The base of the axilla (superior boundary)
• Lateral edge of the pectoralis major (medial boundary)
• 5th intercostal space (inferior boundary)
• Anterior border of latissimus dorsi (lateral boundary).

Question 19

What is the management for primary and secondary pneumothorax?

Answer 19

A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.

Primary pneumothorax

Recommendations include:

• If the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
• Otherwise, aspiration should be attempted
• If this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
• Patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men

Secondary pneumothorax

Recommendations include:

• If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
• Otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
• if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
• regarding scuba diving, the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’

Question 20

Common causes of respiratory alkalosis?

Answer 20

Common causes:

• Anxiety leading to hyperventilation
• pulmonary embolism
• salicylate poisoning*
• CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
• altitude
• pregnancy

*salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis

Question 21

Example of leukotriene receptor antagonist? (LTRA)

Answer 21

Montelukast

Question 22

What are the classical examination findings seen in pleural effusion?

Answer 22

Dyspnoea, non-productive cough or chest pain are possible presenting symptoms

Classic examination findings include:
- Stony dullness to percussion
- Reduced breath sounds
- Reduced air entry
- Reduced chest expansion
- Reduced vocal resonance

(Trachea shifts away from affected side only in massive effusions)

Question 23

Transudate causes of pleural effusion?

Answer 23

Transudate (< 30g/L protein):

• Heart failure (most common transudate cause)
• Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
• Hypothyroidism
• Meigs’ syndrome

(think Failure, heart failure, liver failure, kidney failure)

Question 24

Exudate causes of pleural effusion?

Answer 24

Exudate (> 30g/L protein):

• Infection: Pneumonia (most common exudate cause), TB, subphrenic abscess
• Connective tissue disease: RA, SLE
• Neoplasia: lung cancer, mesothelioma, metastases
• Pancreatitis
• Pulmonary embolism
• Dressler’s syndrome
• Yellow nail syndrome

(Exudate E, think Evil like infection and malignancy)

Question 25

What is the management for acute asthma?

Answer 25

SIGN guidelines give clear instructions on how to escalate care. (O SHIT ME!) 1. Oxygen 2. Salbutamol NEB 3. Hydrocortisone IV OR Oral Prednisolone 4. Ipratropium bromide NEB 5. Theophylline/ IV salbutamol 6. Magnesium Sulfate IV 7. Escalate care (intubation, ventilation)

Question 26

How do you differentiate moderate, severe and life threatening asthma?

Answer 26

Moderate: - PEFR 50-75% best or predicted - Speech normal - RR < 25 / min - Pulse < 110 bpm Severe: - PEFR 33 - 50% best or predicted - Can't complete sentences - RR > 25/min - Pulse > 110 bpm Life threatening: - PEFR < 33% best or predicted - Oxygen sats < 92% - 'Normal' pC02 (4.6-6.0 kPa) - Silent chest, cyanosis or feeble respiratory effort - Bradycardia, dysrhythmia or hypotension - Exhaustion, confusion or coma Note that a patient having any one of the life-threatening features should be treated as having a life-threatening attack.

Question 27

Detailed acute asthma management:

Answer 27

Oxygen - if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy - if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%. Bronchodilation with Short-Acting Beta₂-Agonists (SABA) - High-dose inhaled SABA e.g. salbutamol, terbutaline in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer - In patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended Corticosteroid - All patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack - During this time, patients should continue their normal medication routine including inhaled corticosteroids. Ipratropium Bromide - In patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a Short-Acting Muscarinic Antagonist IV Magnesium Sulphate - BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma IV Aminophylline may be considered following consultation with senior medical staff Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include: - intubation and ventilation - extracorporeal membrane oxygenation (ECMO)

Question 28

The most common cause for bilateral hilar lymphadenopathy?

Answer 28

The most common causes of bilateral hilar lymphadenopathy are sarcoidosis and tuberculosis.

Question 29

Whata are the risk factors for development of aspiration pneumonia?

Answer 29

Aspiration pneumonia is a pneumonia that develops as a result of foreign materials gaining entry to the bronchial tree, usually oral or gastric contents such as food and saliva. Depending on the acidity of the aspirate a chemical pneumonitis can develop, as well as bacterial pathogens adding to the inflammation. Aspiration pneumonia often results from an incompetent swallowing mechanism, such as those that occur in neurological disease or injury such as stroke, multiple sclerosis and intoxication. Iatrogenic causes, such as intubation, can also result in aspiration pneumonia developing. Risk factors for the development of aspiration pneumonia include: - Poor dental hygiene - Swallowing difficulties - Prolonged hospitalization or surgical procedures - Impaired consciousness - Impaired mucociliary clearance The right middle and lower lung lobes are the most common sites affected, due to the larger calibre and more vertical orientation of the right main bronchus.

Question 30

What are the x-ray features seen in left ventricular failure?

Answer 30

Alveolar oedema (Bat's wings) B Kerley B lines (interstitial oedema) Cardiomegaly Dilated prominent upper lobe vessels E Pleural effusion

Question 31

What is the target oxygen saturation in patients with COPD?

Answer 31

88 - 92% Management of COPD patients: - prior to availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis - adjust target range to 94-98% if the pCO2 is normal

Question 32

Stable management for COPD:

Answer 32

General management: - Smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion - Annual influenza vaccination - One-off pneumococcal vaccination - Pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD Bronchodilator therapy - A short-acting beta2-agonist (SABA) OR short-acting muscarinic antagonist (SAMA) is first-line treatment - For patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness' Asthmatic/steroid responsive features: - Any previous, secure diagnosis of asthma or of atopy - A higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up - Substantial variation in FEV1 over time (at least 400 ml) - Substantial diurnal variation in peak expiratory flow (at least 20%) NO asthmatic features/features suggesting steroid responsiveness: - Add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA) - if already taking a SAMA, discontinue and switch to a SABA Asthmatic features/features suggesting steroid responsiveness: - LABA + inhaled corticosteroid (ICS) - If patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS - if already taking a SAMA, discontinue and switch to a SABA - NICE recommend the use of combined inhalers where possible Oral theophylline - NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy Mucolytics - should be 'considered' in patients with a chronic productive cough and continued if symptoms improve

Question 33

What is the FEV1 and FEV1/FFVC in obstructive lung disease?

Answer 33

FEV1 - significantly reduced FVC - reduced or normal FEV1% (FEV1/FVC) - reduced Airflow obstruction is defined as a ratio of FEV1/FVC of less than 0.7. - Asthma - COPD - Bronchiectasis - Bronchiolitis obliterans

Question 34

What is the FEV1 and FEV1/FFVC in restrictive lung disease?

Answer 34

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 35

Example of inhaled corticosteroid (ICS) used in asthma?

Answer 35

Beclometasone dipropionate Budesonide

Question 36

Example of LABA used in asthma?

Answer 36

- Salmeterol - Formoterol

Question 37

Nasogastric aspiration at what pH indicates that the tube is safe?

Answer 37

Nasogastric (NG) tube aspirate should be obtained before administering any feed or medication through the NG tube. If aspirate obtained has a pH <5.5, the NG tube is safe to use. If aspirate >5.5, request a chest x-ray to confirm the position of the NG tube.

Question 38

What is the cause of Alpha-1 antitrypsin deficiency?

Answer 38

Alpha-1 antitrypsin (A1AT) deficiency is a common inherited condition caused by a lack of a protease inhibitor (Pi) normally produced by the liver. The role of A1AT is to protect cells from enzymes such as neutrophil elastase. It classically causes emphysema (i.e. chronic obstructive pulmonary disease) in patients who are young and non-smokers! - Located on chromosome 14 - Inherited in an autosomal recessive / co-dominant fashion* Features: - Lungs: panacinar EMPHYSEMA, most marked in lower lobes - Liver: Cirrhosis and Hepatocellular Carcinoma in adults, Cholestasis in children Ix: - A1AT concentrations - Spirometry: obstructive picture Management: - No smoking - Supportive: bronchodilators, physiotherapy - Intravenous alpha1-antitrypsin protein concentrates - Surgery: lung volume reduction surgery, lung transplantation

Question 39

Example of LAMA used in COPD?

Answer 39

Inhaled tiotropium

Question 40

Investigations used in suspecte lung cancer?

Answer 40

Chest x-ray - this is often the first investigation done in patients with suspected lung cancer - in around 10% of patients subsequently diagnosed with lung cancer the chest x-ray was reported as normal CT - Is the investigation of choice to investigate suspected lung cancer Bronchoscopy - this allows a biopsy to be taken to obtain a histological diagnosis sometimes aided by endobronchial ultrasound PET scanning - is typically done in non-small cell lung cancer to establish eligibility for curative treatment uses 18-fluorodeoxygenase which is preferentially taken up by neoplastic tissue has been shown to improve diagnostic sensitivity of both local and distant metastasis spread in non-small cell lung cancer Bloods raised platelets may be seen

Question 41

What is the mode of inheritance for cystic fibrosis?

Answer 41

Cystic fibrosis (CF) is an autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas). It is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel. Organisms which may colonise CF patients: - Staphylococcus aureus - Pseudomonas aeruginosa - Burkholderia cepacia* - Aspergillus

Question 42

What are the symptoms seen in cystic fibrosis?

Answer 42

Presenting features: - neonatal period (around 20%): meconium ileus, less commonly prolonged jaundice - recurrent chest infections (40%) - malabsorption (30%): steatorrhoea, failure to thrive - other features (10%): liver disease Whilst many patients are picked up during newborn screening programmes or early childhood, it is worth remembering that around 5% of patients are diagnosed after the age of 18 years. Other features of cystic fibrosis: - short stature - diabetes mellitus - delayed puberty - rectal prolapse (due to bulky stools) - nasal polyps - male infertility, female subfertility

Question 43

What are the causes of clubbing?

Answer 43

C- Cyanotic heart disease/ Cystic fibrosis L- Lung cancer U- Ulcerative colitis B- Bronchiectasis B- Benign mesothelioma I-Idiopathic pulmonary fibrosis/ Infective endocarditis N- Neurogenic tumour G- GI causes (liver cirrhosis)

Question 44

Causes of erythema nodosum?

Answer 44

Erythema nodosum: Mnemonic: STORE SHINS S-Sarcoidosis T-tuberculosis O-oral contraceptive pill R-Rickettsia E-Eponym (Behcet’s) S- Sulfamides H-Hansen’s I-IBD N-Non Hodgkin lymphoma S- Strep

Question 45

Trachea deviates AWAY in which conditions?

Answer 45

The trachea deviates away from tension pneumothorax and large pleural effusions.

Question 46

Trachea deviated TOWARDS in which conditions?

Answer 46

The trachea deviates towards lobar collapse and pneumonectomy.

Question 47

Most common bacterial organism cause of infective exacerbation of COPD?

Answer 47

The most common bacterial organisms that cause infective exacerbations of COPD are: Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis

Question 48

Do pleural plaques following asbestosis exposure require follow-up by specialist?

Answer 48

Pleural plaques are benign and do not undergo malignant change. They, therefore don't require any follow-up. They are the most common form of asbestos-related lung disease and generally occur after a latent period of 20-40 years.

Question 49

Common age group affected by idiopathic pulmonary fibrosis?

Answer 49

Idiopathic pulmonary fibrosis is a chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs. Whilst there are many causes of lung fibrosis (e.g. medications, connective tissue disease, asbestos) the term IPF is reserved when no underlying cause exists. IPF is typically seen in patients aged 50-70 years and is twice as common in men. Features - progressive exertional dyspnoea - bibasal fine end-inspiratory crepitations on auscultation - dry cough - clubbing

Question 50

Features of klebsiella pneumonia? Commonly infective organism in which demographic?

Answer 50

Features of Klebsiella pneumonia: - more common in Alcoholic and Diabetics - may occur following aspiration - 'RED-currant jelly' sputum - often affects upper lobes

Question 51

MOA of Varenicline?

Answer 51

Nicotinic receptor partial agonist. It selectively binds to α4β2 nicotinic acetylcholine receptors in the brain, thereby reducing the pleasure and satisfaction associated with smoking. This action helps decrease nicotine cravings and withdrawal symptoms in individuals trying to quit smoking.