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354 Cards in this Set
- Front
- Back
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COPD includes which two diseases?
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Chronic Bronchitis and Emphysema
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What is the typical clinical presentation of COPD?
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Dyspnoea; Chronic cough (productive); Anorexia/Weight Loss
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What is the effect of COPD on respiratory rate?
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Net increase in RR, as increased CO2 retention due to increased dead air space
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The decrease in type 1 muscle fibres and increase in type 2 means what for respiratory function?
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Muscles have less mitochondria, less capillaries and less myoglobin to perform work with, and exhaust more easily
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What hormones are decreased, due to anorexia, in COPD?
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testosterone and IGF-1
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The common cardiopathology seen in COPD is?
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Right Heart Failure (RHF), with decrease cardiac output
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In COPD, what spirometry values are used for FEV1 and FEV1/FVC?
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FEV1 < 80% of predicted; FEV1/FVC < 70%
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In what population should one be cautious about over-diagnosis of COPD?
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The elderly, who have a natural decline in lung function
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Are bronchodilators given to those with COPD?
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Yes, and effectiveness if measured by improvement in QoL
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What is Heliox?
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80% helium and 20% oxygen, used for supplemental O2 in COPD
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What hormone is given (systemically) for therapy in COPD?
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testosterone
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To maintain exercise capacity, what guidelines should be used in monitoring heart rate?
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Patients should aim to keep their heartrate above 60% of Hrmax
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What is the definition of respiratory failure?
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PaO2 < 60mmHg
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What defines chronic bronchitis?
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Productive cough, most days for 3+ months, over 2 years
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What percentage of patients with COPD will have problems performing FVC testing?
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40%
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how many people die from Asthma, in NSW, each year?
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400!
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if someone's FEV1 is 60-80%, what would you rate their Asthma's severity?
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Moderate
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what are frequent contributors to poorly conrolled asthma?
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under-prescribing; poor compliance; trigger exposure; poor inhaler technique
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how many puffs can be taken from an inhaler before it is exhausted?
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200
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what questions should be asked to assess asthma control?
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over last 2-4 weeks: 1) frequency of inhaler usage, 2) experienced symptoms, 3) been woken at night, 4) had unplanned time off
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how many times per week can someone be using their asthma reliever before ICS should be added/adjusted?
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3 or more times per week
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if someone's asthma is well controlled, how can you achieve 'stepping down' of medication?
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if someone has effective control for 6-12 weeks, they can reduce in 200mcg increments (400mcg if on >1200mcg) at a time
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what are common environmental triggers of asthma?
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smoke, dust, dust mites, pollen, spores, animal dander, cold air, sudden temperature change, exercise, strong smells, MSG, certain foods, URTIs, stress
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what is maintenance medication for very mild asthma?
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SABA (PRN)
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what dose of ICS (FP) should be used for mild asthma? Moderate? Severe?
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(mild) <250FP; (mod) 250-500FP; (severe) 500-1000FP
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when should LABA be added to one's asthma control?
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for moderate to severe asthma
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what are the suffixes for ICS?
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-sone or -nide, commonly
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how long is the effectiveness of LABAs?
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12 hours
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clinical trials show that 90% of the benefit of 1000mcg/day dose of ICS can be achieved with what dose?
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100-250mcg/day
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how many times per week can someone get nightime asthma syptoms before they should be put on ICS?
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once a week
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what preventative measures can be taken to minimize local (oral) adverse effects of ICS?
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volume spacer; rinse mouth; minimize dose; supplement with LABA
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what are some long term adverse effects of ICS?
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psychiatric disturbances; cataracts; adrenal suppression; skin changes; effects on bone metabolism
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what are the long term adverse effects known for children taking 100-200ug/day of ICS?
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none known so far (nil growth restriction)
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T/F: ICS + LABA provides better control than that of double the ICS dose?
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True
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when should someone be admitted for their asthma attack?
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If clinical features persist after initial treatment; PEF < 150; PEV1 < 1L; Social issues; presentation despite previous oral steroids
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at the age of 75, how does one's lung function compare to that at age 25?
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about 75%
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how should one adjust their asthma medication with a cold?
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increase both ICS and BD
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how often should a 'high risk' asthma patient be reassessed?
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every 3/12
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if a solitary pulmonary nodule doesn't not change over 2 years, should one continue monitoring it?
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Not necessary to, as it is most certainly benign
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at what size are solitary pulmonary nodules evident on imaging?
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>9mm
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what percent of solitary pulmonary nodules <2cm are benign?
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>50%
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is a spiculated border on a pulmonary nodule a good prognostic indicator?
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No; 90% of these are malignant
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what is a favorable appearance for a border of a solitary pulmonary nodule?
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A smooth border
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which lung do solitary pulmonary nodules mostly occur in?
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The right lung (1.5x the amount of the left)
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what percent of lung cancers occur in the upper lobes of the lungs?
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70%
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why are lung cancer around the periphery of the lungs on the rise?
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due to low-tar cigarettes, which allow deeper inhalation and permeation to the periphery
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what percent of lung cancers display evidence of calcification?
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13% (though calcified nodules are usually benign, do not be reassured by this trait)
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if a single pulmonary nodule has a wall that is <4mm thick, what are the chances it is benign?
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95%
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what is the prototypical solitary pulmonary nodule which cavitates?
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SCC of the lung
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in assessing a pulmonary nodule, what does VDT stand for?
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Volume Doubling Time (v. sensitive to human error, but used often)
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what speed of Volume Doubling Time is used to assess a pulmonary nodule as having a high likelihood of malignancy?
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VDT < 500 days
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what investigations should be performed for a solitary pulmonary nodule?
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FNAB; PET scan measuring standard uptake value (SUV)
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what are the 4 diagnostic criteria for Acute Respiratory Distress
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1) acute onset, 2) bilateral infiltrates [CXR], 3) hypoxemia, despite supplementation, 4) no evidence of pulmonary HTN
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what is the mortality rate for ARDS?
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30-50%
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what is the only therapy which reduces mortality in ARDS?
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Mechanical ventilation (Low-tidal volume, plateau-pressure-limited)
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what are risk factors for ARDS? (list 3)
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critical illness; alcohol misuse; sepsis; aspiration; severe trauma; pneumonia; pancreatitis; burns/smoke inhalation; blood transfusions; lung transplant
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what cultures should be sought in ARDS?
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1) sputum, 2) blood, 3) urine
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what is the definition of hypoxemia in ARDS?
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PaO2/FiO2 < 200
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Pulmonary fibrosis is an example of what lung disease?
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Restrictive Lung Disease
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Restrictive lung diseases have what common pathology?
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Imbalance of collagen turnover
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what is the clinical presentation of restrictive lung disease?
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Dyspnoea; Cough; Clubbing; Cor pulmonale; Constitutional symptoms; Crackles; Cyanosis
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what environmental exposure is important to elicit in a respiratory history?
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asthma triggers; smoking; asbestos; silica dust; coal dust; diesel; other occupational toxins
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how does FEV1/FVC appear in someone with restrictive lung disease?
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normal to high (reduced compliance = stiff)
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what is the definition of pulmonary sarcoidosis?
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non-caseating granulomas, interstitial fibrosis and monocyte alveolitis
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what is the prognosis for stage I sarcoidosis?
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two-thirds will spontaneously resolve; the rest will progress
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what ethnicity is high risk for sarcoidosis?
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Scandinavian heritage
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what eye symptoms are common with sarcoidosis?
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red painful eye; photophobia; blurred vision
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what is stage I pulmonary sarcoidosis?
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(performed with CXR) bilateral hilar lymphadenopathy, with no pulmonary infiltrate
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what is the mainstay of treatment for early sarcoidosis?
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oral corticosteroids, and ventilatory support for acute exacerbations
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What are the three classic examples of pneumoconiosis?
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Coal worker's lung, silicosis, asbestosis
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how long does pneumoconiosis take to develop after exposure?
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30-40 years
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how does pneumoconiosis appear on chest X-ray?
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white lines at the base of the pleura
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what is heard on auscultation of asbestosis?
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fine crackles
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what is the prognosis after diagnosis with asbestosis?
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1 year
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why is there alveolar thickening in pneumoconiosis?
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pneumocytes are killed off, and type II pneumocytes divide faster than they differentiate (they are thicker than type I)
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In the first three months of life, what are the (4) leading causes of pneumonia?
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Chlamydia; RSV; other respiratory viruses; Bordetella pertussis
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In adults, what are the (3) leading causes of pneumonia?
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Mycoplasma pneumoniae; Streptococcus pneumoniae; Chlamydia pneumoniae
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What are the common causes of hospital acquired pneumonia?
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Klebsiella pneumoniae; Pseudomonas aeruginosa; Staphlyococcus aureus
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what are the four phases of pneumonial infection?
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1) congestion, 2) red hepatization, 3) grey hepatization, 4) resolution
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what are the six items assessed to grade the severity of pneumonia?
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1) age [>60], 2) RR [>30bpm], 3) multi-lobe involvement, 4) new atrial fibrillation, 5) WBC, 6) diastolic [BP < 60mmHg]
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a severity score of 2 (moderate) for community-acquired pneumonia, should be commenced on a treatment of?
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augmentin (oral)
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a severity score of 3+ (severe) for community-acquired pneumonia, should be commenced on what treatment?
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ceftriaxone or azithromycin (IV)
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nosocomial infections of pneumonia should be commenced on what treatment?
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gentamicin OR ticarcillin/clavulanate
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what portion of the world is infected with TB?
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1/3
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what is the annual risk of reactivation of TB, in someone with HIV?
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10%
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what diameter Mantoux test is unequivocally negative?
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<5mm
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what diameter of Mantoux test is positive?
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if not vaccinated: >10mm; >15mm otherwise
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what is one looking for in the sputum of someone being investigated for TB?
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acid-fast bacilli (AFB)
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what is the name of the quarantined therapy someone with TB receives at home?
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DOT - direct observed therapy
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what organ commonly is seeded in TB, from the lungs, and needs monitoring?
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the liver
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what antibiotics are used in combination, for TB?
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isoniazid, rifampicin, ethambutal, pyrazinamide (w/B6)
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In pulmonary function tests (PFTs), what is the cutoff for 'normal' results?
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>80% of predicted
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T/F: Patients with obstructive lung disease can have increased TLC?
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True: patients often have hyperinflated lungs
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How is vital capacity calculated?
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TLC - RV = VC
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How is COPD diagnosed?
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Forced Expiratory Flow (FEF) + bronchodilator reversibility
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In obstructive lung disease, what FEV1/FVC is seen?
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<0.70
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In restrictive lung disease, what FEV1/FVC is seen?
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a high ratio; >0.80
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In restrictive lung disease, what TLC is seen? RV? VC?
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Each (TLC/VC/RV) are low
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Diffusing Lung Capacity of CO (DLco) is used to measure what?
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ability of O2 to pass from alveoli to blood
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In what form of COPD is DL(CO) decreased?
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emphysema
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What are three connective tissue diseases that can cause alveolar haemorrhage, and thereby an increased DL(CO)?
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Wegener's, Goodpasture's, SLE
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How do normal/healthy patients react to a methacholine challenge test?
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bronchorestriction
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A methacholine challenge test is considered positive if provocation causes what percent decrease in PFTs?
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20%
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How does one differentiate between asthma and COPD on PFTs?
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Bronchodilator reversibility
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On a flow volume loop, which direction is an obstructive pattern shifted? Restrictive?
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Obstructive: LEFT. Restrictive: RIGHT
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In a hypoxemic patient, what is the most important factor for maintaing oxygen delivery in the patient?
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Hb > 100 (transfuse if below)
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What is the formula for calculating the A-a gradient?
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A-a gradient = (150 - 1.25xPaCO2) - PaO2
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What is the normal PAO2 in alveoli?
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100 mmHg
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What is the normal PaCO2 in arterial blood?
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40 mmHg
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If a patient is hypoxemic and has a high A-a gradient, what are the two possible causes?
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Pulmonary or L->R shunt in the heart
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Upon finding a solitary pulmonary nodule on CXR, what is the next best step?
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Look at previous CXRs if available
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How long should one monitor a solitary pulmonary nodule, if no changes are seen?
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Every 3 months, for 2 years
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What are benign solitary nodules commonly attributed to?
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Previous lung infections
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If a solitary pulmonary nodule is not present in previous CXRs or they are not available, what is the next step in management?
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Stratify in to low or high risk group for management
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With a solitary pulmonary nodule, what three criteria determine a patient to be 'low risk'?
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1) no smoking history, 2) <45 yrs old, 3) asymptomatic
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If an individual with a SPN is stratified as 'high risk' what is the next best step in management?
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open lung biopsy, and remove nodule
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If a patient presents with dyspnoea and CXR shows free flowing fluid, what is the next best step?
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thoracocentesis (always done immediately!)
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What are the four most common causes of pleural effusion?
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1) infection, 2) TB, 3) cancer, 4) PE
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What three parameters are measured in an effusion to determine if it is an exudate or transudate?
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LDH (effusion), LDH (effusion:serum), protein (effusion: serum)
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What three values must an effusion have for LDH, LDH effusion/serum ratio & protein effusion/serum ratio, in order to be called 'transudate'?
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LDH < 200, LDH effusion:serum < 0.6, protein effusion:serum < 0.5
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What systemic features cause a transudate in the lungs?
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an increase in hydrostatic pressure, or decrease in oncotic pressure
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What is the most common causative organism of Community-Acquired Pneumonia?
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Strept Pneumoniae
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When does pneumonia require a chest tube for drainage?
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When it is considered 'complicated' (ie. Effusion is infected; Gm+, culture, pH)
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What are the three top causes of a haemorrhagic effusion in the lungs?
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1) TB, 2) cancer, 3) pulmonary emboli
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What are the two common causes of lymphocytic exudative effusion in the lungs?
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TB or lymphoma
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T/F: if malignant cells are found in the effusion of the lungs, the SPN is not resectable?
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True: This classifies the cancer as Stage IIIb (unresectable)
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If lung effusions are not infected, how should they be treated?
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Treat the underlying disease, not the effusion directly
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If a patient has respiratory distress and is given O2, what is the target range for SaO2?
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88-92% (so as to not suppress respiratory drive)
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What respiratory rate is considered 'mild' respiratory distress, and should be re-evaluated often?
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>20 breaths/min
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On auscultation, wheezes are indicative of?
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Obstruction (Asthma or COPD in adults; Foreign body* or asthma in a child)
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On auscultation, fine crackles are indicative of?
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Pneumonia or Interstitial Lung Disease
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What is the most important investigation for a patient in respiratory distress?
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ABGs
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If a patient has respiratory distress and the CXR is normal, what is the most likely cause?
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Pulmonary emboli
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In respiratory distress, what marker should be investigated to exclude heart failure?
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B-natriuretic peptide
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What criteria determine if a patient in respiratory distress should be admitted to ICU and intubated?
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a) persistent hypoxemia, b) increasing oxygen demands, c) hypercapnea in asthma, d) upper airway injury [burns, larygeal oedema], e) altered mental status, f) neurologic depression
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what proportion of childhood asthma will be outgrown?
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2/3
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does idiosyncratic or atopic asthma have a better outcome?
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atopic
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what are the three most common precipitants of an asthma attack?
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1) viral infections, 2) drugs [ASA, beta-blockers], 3) exercise
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In an asthma attack, how does one determine if pulsus paradoxus is present?
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To determine if pulse changes >20 mmHg with inspiration/expiration, feel radial pulse and note if it disappears on inspiration
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What are two features of 'atypical asthma'?
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1) nocturnal cough, 2) exercise-induced
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What three investigations should be performed for an acute exacerbation of asthma?
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1) ABGs [hypoxemia; resp fatigue], 2) CXR [infiltrates], 3) pulse oximetry [continuous monitoring]
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what is the most important step in confirming the diagnosis of asthma?
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PFTs
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After supplemental oxygen, what is the next best step in management of an acute exacerbation of asthma?
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SABAs
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Which should be used for an acute exacerbation of asthma in the ED: SABAs or LABAs?
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SABAs
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What common OTC drugs may cause exacerbations of asthma?
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NSAIDs/ASA
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How is an acute exacerbation of asthma managed in the ED?
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1) O2, 2) SABA [second line - anticholinergics such as tiotropium], 3) IV steroids Stat [transition to oral for 14 day]
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how long do IV corticosteroids take to take effect in acute asthma?
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24-48 hours
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In acute asthma, how long should steroids be taken for?
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10-14 days
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What percent of asthmatics take more than one drug for management?
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80%
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What is the most important aspect of chronic asthma management?
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daily inhaled corticosteroids
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How can the bad taste associated with ICS be avoided?
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a) washing out mouth after, b) turbo-halers
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what are the two common side-effects of systemic absorption from ICS?
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1) cataracts, 2) osteoporosis
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What alternative can be used, instead of ICS, in children?
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Mast cell stabilizers, such as cromolyn or nedocromil
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What medication is useful for prophylaxis against exercise-induced asthma?
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Mast cell stabilizers, such as cromolyn or nedocromil
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What medication is used for nocturnal symptoms of asthma?
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LABAs
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What are some names of SABAs?
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ventolin, salbutamol, sandoz
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what are the names of some LABAs?
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salmeterol, bambuterol, formoterol (symbicort)
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what are the names of some inhaled corticosteroids?
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fluticasone, beclomethasone, budesonide
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when are oral corticosteroids indicated for asthma?
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for severe cases only
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what medication options are available to reduce ICS usage?
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LABAs or Leukotriene inhibitors (eg. Montelukast)
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When should theophylline/aminophylline be used in asthma?
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Generally not recommended; only for status asthmaticus
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What is the next best step in a patient presenting for the first time with night-time cough, and no diagnosis of asthma?
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4-week trial of omeprazole (for post-nasal drip, which is more likely than asthma)
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If an asthmatic patient presents with worsening symptoms and nasal polyps are evident, what advice should be given?
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Avoid ASA/NSAIDs
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If a patient appears to have symptoms of obstructive lung disease, and PFTs show a decreased DL(CO), what is the diagnosis?
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emphysema
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What is the next best step for a patient presenting with acute asthma, and ABGs of 7.2/65/60?
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admit to ICU and intubate
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If an asthmatic patient presents with bilateral upper lobe infiltrates, and a positive prick test to aspergillus, what is the next best step?
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High dose steroids (auto-immune reaction triggered by aspergillus)
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What is the name of the autoimmune reaction triggered by aspergillus?
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Allergic Bronchopulmonary Aspergillosis
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What asthma medications are associated with Churg-Strauss syndrome?
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Leukotriene inhibitors
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What antibiotics are not-excreted by the kidneys (ie. Safe in renal failure)
|
1) tetracyclines, 2) chloramphenicol, 3) macrolides
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what is the diagnostic criteria for Chronic Bronchitis?
|
productive cough for 3 months, for 2 consecutive years
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In the chronic state, is COPD an inflammatory condition?
|
No
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What is the number one cause of COPD?
|
smoking
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What rare protein deficiency can cause emphysema?
|
alpha-1-antitrypsin (tend to be younger presentation)
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On auscultation, what would one hear in COPD?
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distand heart sounds [hyperinflation], rhonchi/wheezing
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what is the prognosis if cor pulmonale is present in COPD?
|
poor; mortality is greatly increased
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when is the typical onset of COPD?
|
in the 6th-7th decade of life
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what CXR findings are consistent with COPD?
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hyperinflated lungs; flattened diaphragm; slender heart
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what ABGs are typical of a person with COPD?
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CO2 near equal O2; "60-60"
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what is the most effective bronchodilator in COPD, and the mainstay of chronic management?
|
ipratropium
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which is better for usage in COPD: SABAs or LABAs?
|
SABAs (which are less effective than ipratropium). LABAs should be avoided.
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what is the mechanism of action of ipratropium?
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blocks muscarinic acetylcholine receptors, in smooth muscles
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if ipratropium and a SABA are inadequate therapy for COPD, what may be added?
|
theophylline, but should be avoided due to its toxicity and interaction with macrolides
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what is the action of theophylline?
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aids in retraction of the diaphragm
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can theophylline be administered PRN for COPD?
|
no, it should be used continuously; once usage has begun it should continue indefinitely
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what antibiotics does theophylline interact with?
|
macrolides (ie. Erythromycin)
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what lifestyle behaviour may affect theophylline treatment?
|
smoking, which alters metabolism of it, rending it less effective
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what three interventions have been shown to increase survival in COPD?
|
1) quite smoking, 2) home O2, 3) vaccinations
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when is it recommended that a COPD patient commence home oxygen therapy?
|
a) PaO2 < 55, b) PaO2 < 59, w/cor pulmonale, c) desaturation with exercise
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if a COPD patient does not wish to use home oxygen all the time, what time of day should they ensure to continue usage?
|
when sleeping, when desaturation becomes worse
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what vaccinations should be given in COPD, and how often?
|
a) influenzae - yearly, b) pneumococcal - Q5years, c) H influenzae - once
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what time of year are COPD patients more likely to come in to hospital with an acute exacerbation?
|
wintertime
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what investigations should be done for acute COPD, upon presentation to hospital?
|
a) ABGs, b) O2/oximetry, c) CXR, d) FBC, electrolytes, e) ECG, f) theophylline levels
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for acute COPD, when should a patient be admitted to hospital (3 criteria)?
|
a) changes in CO2/O2 from baseline are significant, b) symptoms are severe, c) pneumonia is suspected
|
|
|
when should intubation be considered for an acute COPD exacerbation?
|
if there is an altered level of consciousness, OR haemodynamically unstable
|
|
|
on admission to hospital, how should acute COPD be managed?
|
a) O2 supplementation [PaO2 ~90%], b) bronchodilators [ipratropium/salbutamol], c) systemic corticosteroids, d) antibiotics [macrolides/cephalosporins/fluoroquinolones], e) theophylline [continue current usage]
|
|
|
if an acute COPD is not taking theophylline, is this a useful supplement to add to their regimen?
|
yes, but not until exacerbation is over; if they are already taking it, though, it should not be stopped
|
|
|
should antibiotics be given to an acute COPD if the CXR is normal?
|
yes, they are still given
|
|
|
what two things should a COPD patient be counselled on before leaving hospital?
|
1) tobacco cessation, 2) optimal MDI usage
|
|
|
how long should one take corticosteroids for an acute COPD exacerbation?
|
10-14 days (start IV, switch to oral, and taper down until review for cessation)
|
|
|
what antibiotics should be used for acute COPD?
|
macrolides OR cephalosporins OR fluoroquinolones
|
|
|
how is the extent of severity assessed in COPD?
|
PFTs
|
|
|
if a COPD admission is assessed to have cor pulmonale, what are the next steps in management?
|
CXR, ECG & BNP
|
|
|
what enzyme does alpha-1-antitrypsin normally inhibit?
|
elastase
|
|
|
bronchiectasis affects which sized bronchioles?
|
small and medium bronchioles
|
|
|
Cystic Fibrosis results in what lung disease?
|
Bronchiectasis
|
|
|
Localized bronchiectasis is caused by?
|
Pneumonia
|
|
|
What is the typical presentation of bronchiectasis?
|
copious, purulent sputum; recurrent pneumonias; haemoptysis
|
|
|
what is the causative organism in the recurrent pneumonias of bronchiectasis?
|
Gram-negative bacteria (Pseudomonas*)
|
|
|
what is the best non-invasive test for diagnosis of bronchiectasis?
|
high-resolution CT scan
|
|
|
what CXR findings are consistent with bronchiectasis?
|
"tram lines"
|
|
|
what antibiotics can be used for acute pneumonia in bronchiectasis?
|
anti-pseudomonas penicillins, aminoglycosides, fluoroquinilones
|
|
|
How is localized bronchiectasis managed chronically?
|
surgery, for excision of affected area
|
|
|
how is diffuse bronchiectasis managed chronically?
|
a) bronchodilators & ICS, b) physiotherapy, c) rotating Abx, d) vaccinations
|
|
|
Is inflammation present in interstitial lung disease?
|
Yes, there is chronic inflammation
|
|
|
what are the clinical symptoms common to interstitial lung diseases?
|
a) exertional dyspnoea, b) fine crackles, c) clubbing, d) cor pulmonale
|
|
|
what CXR findings are consistent with interstitial lung disease?
|
reticular pattern, with ground-glass appearance
|
|
|
what PFT findings are consistent with interstitial lung disease?
|
restrictive pattern, with decreased DL(CO)
|
|
|
after initial CXR and PFTs for interstitial lung disease, what is the next best step?
|
high-resolution CT scan (determine area affected), and biopsy
|
|
|
what is the interstitial lung disease where no cause is found, and no organ but the lungs are involved?
|
Idiopathic Pulmonary Fibrosis (IPF), the diagnosis of exclusion
|
|
|
at what age does idiopathic pulmonary fibrosis typically occur?
|
in 40s
|
|
|
what investigations should be done to verify idiopathic pulmonary fibrosis?
|
bronchoscopy and lavage, which can help exclude other diseases
|
|
|
what is the treatment for idiopathic pulmonary fibrosis? What is the response rate?
|
steroids, to which 20% of people will respond
|
|
|
how is the efficacy of steroid treatment on idiopathic pulmonary fibrosis monitored?
|
by PFTs every 3 months
|
|
|
how long should one trial a course of prednisone (60mg) for in IPF, before ceasing if no benefit is seen?
|
one year
|
|
|
what is the pulmonary feature of sarcoidosis?
|
interstitial lung disease with non-caseating granulomas and bilaterla hilar adenopathy
|
|
|
besides the lung, what other organs are commonly affected in sarcoidosis?
|
skin; eye (uveitis/conjunctivitis); joints; CNS; peripheral nerves; GIT; kidneys
|
|
|
sarcoidosis patients experience hypercalcaemia at what time of year? Why?
|
In summertime, due to hyperactivation of the macrophages from the sunlight
|
|
|
what is the prognosis for sarcoidosis?
|
80% of restrictive lung cases will spontaneously resolve on their own
|
|
|
when should steroids be used in sarcoidosis?
|
when there is involvement of the eye, CNS or hypercalcaemia
|
|
|
how is sarcoidosis of the lung diagnosed?
|
by tissue biopsy, showing non-caseating granulomas
|
|
|
what pattern of joint involvement is seen in sarcoidosis?
|
symmetrical, polyarticular arthropathy
|
|
|
what utility are ACE levels in sarcoidosis?
|
monitoring disease process in the lungs
|
|
|
how long does pneumoconiosis take to manifest after exposure?
|
20-30 years typically
|
|
|
how is pneumoconiosis diagnosed?
|
biopsy
|
|
|
silicosis affects which region of the lungs?
|
infiltrates of the upper lung
|
|
|
a CXR with a nodular pattern & eggshell calcifications in the upper lungs is consistent with which restrictive lung disease?
|
silicosis
|
|
|
what disease should those with silicosis be screened for each year? What is the diagnostic criteria?
|
pulmonary tuberculosis, for which they are considered positive if fibrosis > 10mm is found on CXR
|
|
|
how does coal worker's pneumoconiosis appear on CXR?
|
small round densities in the upper lobes
|
|
|
what immunologic abnormalities are found in coal workers pneumoconiosis
|
IgA/G increased, C3 decreased, and ANA is positive
|
|
|
what CXR findings are unique to asbestosis?
|
pleural plaques
|
|
|
on CXR where are the infiltrates found in asbestosis?
|
lower lobes
|
|
|
which type of cancer are asbestosis patients most likely to get, rather than mesothelioma?
|
Bronchogenic cancer (75x the risk if a smoker)
|
|
|
The origin of 80-90% of Pulmonary emboli is?
|
Proximal DVTs
|
|
|
The origin of most proximal DVTs is?
|
Distal DVTs
|
|
|
What atypical location for DVTs are pregnant women susceptible to?
|
abdominal DVTs
|
|
|
What is a paradoxical thromboembolism?
|
Where an emboli passes through a patent foramen ovale, and enters the arterial system
|
|
|
What are the clinical features of a pulmonary embolism?
|
(sudden onset) dyspnoea, thigh/calf swelling, pleuritic chest pain, haemoptysis, tachycardia, tachypnoea
|
|
|
High risk patients for PE, include …? (list 4)
|
a) recent surgery [orthopaedic], b) cancer, c)immobilized, d) OCPs, e) Lupus anticoagulant, f) inherited thrombophilia, g) pregnancy
|
|
|
why does nephrotic syndrome put patients in a thrombophilic state?
|
Loss of anti-thrombin III (same size as albumin) in urine
|
|
|
what is the most commonly acquired thrombophilia?
|
Factor V Leiden
|
|
|
What changes occur in pregnancy, creating a thrombophilic state?
|
Protein C & S activity decreased; fibrinogen & FII,VII increased
|
|
|
What protein does heparin enhance the function of?
|
Antithrombin III
|
|
|
In the ABGs of a patient with a PE, should results be hypoxemic with an increased A-a gradient?
|
Most of the time, but young healthy patients may have normal results
|
|
|
What CXR findings are consistent with a PE?
|
Usually normal, but may have some effusion (can cause exudate or transudate)
|
|
|
What findings may be noted on the ECG of someone with a PE?
|
tachycardia, and S1/Q3/T3
|
|
|
what is the first option investigation for a suspected PE? What is it's shortcoming?
|
Spiral CT scan. Short-coming: may miss small peripheral Pes
|
|
|
Which part of the V/Q scan should be performed first?
|
Perfusion. If it is normal, then no need to perform the Ventilation
|
|
|
What is the gold standard investigation for PE?
|
Angiogram
|
|
|
If a spiral CT and D-dimer are both negative, can one rule out a PE?
|
Yes
|
|
|
What is the most sensitive (not specific) test for PE/DVT?
|
D-dimers
|
|
|
which should be done first for a suspected PE: spiral CT or heparin?
|
Heparin should be commenced prior to other investigations
|
|
|
In suspected PE, what is the next best step in care, after ABGs, CXR and ECG?
|
Heparin
|
|
|
when are thrombolytics used in PE?
|
only for unstable thromboembolic disease
|
|
|
when is a thrombectomy indicated in PE?
|
only for unstable thromboembolic disease, where thrombolytics are contraindicated
|
|
|
when should a patient receive lifelong anticoagulation for their PE/DVT?
|
for recurrent PE/DVTs, especially those with thrombophilias
|
|
|
how long does primary heparin-induced thrombocytopenia take to occur?
|
5-7 days after initiating treatment
|
|
|
How should PE be managed, in a patient that is haemodynamically stable, but anticoagulation is contraindicated?
|
insert an IVC filter
|
|
|
How should PE be managed, in a patient that is haemodynamically stable, and no contraindications to antiocoalatin?
|
commence heparin/warfarin, and continue anticoagulation for 6 months
|
|
|
How should a PE be managed in a patient that is unstable, and has had major surgery recently?
|
pulmonary embolectomy & IVC filter
|
|
|
How should a PE be managed in a patient that is unstable, but not contraindications to anticoagulation?
|
Thrombolytic therapy (tPA, streptokinase, urokinase, etc), plus anticoagulation therapy for 6 months
|
|
|
Why are persons with Factor V Leiden mutation more susceptible to thrombophilia?
|
The mutation impairs Protein C's ability to degrade activated Factor V in coagulation
|
|
|
Young women with a history of spontaneous abortions and DVTs should be investigated for?
|
Lupus anticoagulant
|
|
|
If a person presents with symptoms of a PE several days after a long-bone fracture, and petechiae and confusion are noted, the likely diagnosis is?
|
Fat embolism
|
|
|
How is a fat embolism managed?
|
Oxygen (& steroids?). Anticoagulation should be avoided
|
|
|
what is the pathology behind Acute Respiratory Distress Syndrome?
|
increased alveolar-capillary permeability, allows non-cardiogenic pulmonary oedema
|
|
|
what are the three leading causes of ARDS?
|
1) sepsis, 2) trauma, 3) DIC, tied with overdose
|
|
|
how does Acute respiratory distress syndrome appear on CXR?
|
As a 'white out'
|
|
|
what is the preferred treatment for a pneumothorax?
|
Thoracostomy
|
|
|
patients with limited sleroderma and Raynaud's disesase are at high risk of what pulmonary pathology?
|
pulmonary hypertension
|
|
|
if a free-floating pleural effusion is found on CXR, what is the next best step in management?
|
thoracocentesis
|
|
|
What antihypertensive medication should be avoided in asthmatics?
|
non-selective Beta-blockers
|
|
|
How is a diagnosis of exercsie-induced asthma confirmed?
|
with a exercise challenge test, showing post-exercise drop in FEV1 of >20%
|
|
|
Should antibiotics be used in the treatment of acute bronchitis, in COPD patients?
|
Yes
|
|
|
how many times per hour do persons with OSA cease breathing each hour?
|
10-15 times
|
|
|
on ABGs, what abnormality would be found in OSA patients?
|
increased bicarbonate +/- oxygen desaturation
|
|
|
aside from daytime somnelence, what sequelae are OSA patients are risk of?
|
HTN and cor pulmonale
|
|
|
if weight loss and CPAP are unsuccessful in managing OSA, what surgery might be done?
|
uvulectomy
|
|
|
How is central sleep apnea diagnosed?
|
polysomnography (sleep study)
|
|
|
how is central sleep apnea treated?
|
acetazolamide (stimulated breathing) or progesterone
|
|
|
what is the leading cause of death from cancer?
|
lung cancer
|
|
|
what percent of lung cancers are attributed to smoking?
|
90%
|
|
|
in a non-smoker, what lung cancer is most prevelant?
|
adenocarcinoma
|
|
|
10 years after quitting smoking, what is an ex-smokers risk of lung cancer?
|
1.5-2.5x that of a non-smoker
|
|
|
what test might be used to screen for lung cancer?
|
None, though CTs might be used to catch disease early
|
|
|
what is the most common presenting complaint for lung cancer?
|
cough
|
|
|
why does lung cancer often cause recurrent pneumonia?
|
post-obstruction pneumonia, due to the mass, hence its recurrence in the same location
|
|
|
what criteria deem a lung cancer non-resectable? (5 items)
|
1) hoarseness [sign of mets], 2) mets to distant organs, 3) mets to pleura, 4) mets to other lung, 5) lesion close to carina
|
|
|
metastasis to a distant organ is a sign of a non-resectable lung cancer. What is the exception to this?
|
A single met in the brain
|
|
|
What are three sequelae of a Right Apical Lung Tumour?
|
a) SVC syndrome [emergency!], b) Pancoast syndrome, c) Horner syndrome
|
|
|
If a patient with lung cancer presents with SVC syndrome (flushing, JVD, confusion), how is this managed?
|
Immediate radiation therapy (& biopsy first if possible)
|
|
|
What is Pancoast syndrome?
|
When an apical lung tumour invades the brachial plexus
|
|
|
What is the triad of symptoms seen in Horner's syndrome?
|
Miosis, Ptosis and Anhydrosis
|
|
|
What two types of bronchogenic cancers usually are centrally located?
|
a) small-cell, and b) squamous
|
|
|
what two types of bronchogenic cancers usually are peripherally located?
|
a) large-cell, and b) adenocarcinoma
|
|
|
What type of lung cancer is hypercalcaemia associated with?
|
Squamous cell (paraneoplastic syndrome of PTH-like hormone)
|
|
|
Which type of bronchogenic lung cancer has the worst prognosis?
|
Small-cell Carcinoma
|
|
|
Paraneoplastic syndromes of SIADH, Cushing Syndrome and Lambert-Eaton syndrome are associated with which lung cancer, commonly?
|
Small-cell Carcinoma
|
|
|
In diagnosing lung cancer, is sputum at all useful?
|
Yes, it is able to provide diagnosis in 1/3 of the cases
|
|
|
If a SPN is located centrally, how might a sample be obtained for dianosis?
|
Bronchoscopy
|
|
|
If a SPN is located peripherally, how might a sample be obtained for diagnosis?
|
Needle biopsy
|
|
|
Is pulmonary effusion useful for diagnosis in cancer?
|
Yes, it can help determine the cell type and the staging
|
|
|
If a needle biopsy show a lung cancer to be bronchoalveolar adenocarcinoma, what investigation should be used for staging?
|
CT or MRI. PET scan is useful for other types, but may not detect mets of this slow growing type.
|
|
|
If a lung cancer patient has no mets, what PFTs criteria is used to determine if they are a surgical candidate?
|
If FEV1 > 50% of predicted (not often the case, due to COPD)
|
|
|
Is a spiculated appearance of a SPN indicative of cancer? Calcification? Cavitation? Popcorn appearance?
|
Spiculation: yes. Calcification: no (but does not rule out). Cavitation: yes (SCC). Popcorn: no
|
|
|
what is the 5 year survival for Stage 1 NSCLC (ie. No invasion beyond the lung)
|
50%
|
|
|
if a patient with NSCLC has ipsilateral hilar node involvement, what is the 5 year survival?
|
30% (Stage II)
|
|
|
what is the 5 year survival for Adenocarcinoma of the Lungs?
|
12% (metastasizes early)
|
|
|
shortness of breath immediately after surgery is most likely due to?
|
atelectasis, the most common post-op complication. Usually self-limiting
|
|
|
what are the two non-surgical causes of atelectasis?
|
a) cancer, b) foreign body
|
|
|
what are the clinical signs of atelectasis?
|
poor inspiration; lack of cough; tachycardia; dyspnoa; tracheal deviation
|
|
|
what is the treatment of atelectasis?
|
incentive spirometry
|
|
|
what are the three cardinal signs of a lung infection?
|
1) fever, 2) cough, 3) sputum
|
|
|
what is the leading causative organism of lung infections?
|
Strep pneumoniae
|
|
|
what is the most common organism to cause pneumonia in alcoholics? HIV?
|
Both: Strep pneumoniae
|
|
|
what is the most decisive test for pneumonia?
|
blood culture
|
|
|
what signs point to the cause of lung infection being due to an abscess?
|
severe fever, air-fluid levels on CXR, poor dentition, foul breath, slow onset
|
|
|
what is the most accurate test for diagnosis of a lung abscess?
|
biopsy
|
|
|
what antibiotic(s) should be used for a lung abscess?
|
penicillin or clindamycin (used against respiratory anaerobes)
|
|
|
what clinical features point to bronchitis as the cause of a lung infection?
|
mild fever, normal CXR, short onset
|
|
|
what change to blood sugar levels are seen in severe pneumonia?
|
hyperglycaemia
|
|
|
how is admission criteria decided for community acquired pneumonia?
|
severity (hypoxia, dyspnoea, hypotension, confusion, tachycardia, hyperglycaemia, hyponatraemia, high WBCs, pre-existing comorbidities)
|
|
|
what antibiotic(s) should be used for an outpatient with pneumonia?
|
amoxycillin OR doxycycline OR clarithromycin
|
|
|
what antibiotic(s) should be used for an inpatient with pneumonia?
|
caftriaxone/benzylpenicillin + gentamicin/cefotraxime + azithromycin
|
|
|
which patients with pneumonia should receive vaccinations against pulmonary infections?
|
Those with severe cases, and those >65 yo
|
|
|
what is an atypical pneumonia?
|
Gram negative, and regular culture is negative
|
|
|
what atypical organism should be suspected in pneumonia in someone with HIV?
|
PCP (pneumocystis pneumonia, aka pneumocystosis)
|
|
|
How is a PCP infection treated?
|
TMP (Bactrim) & oxygen. Steroids for severe cases (PaO2 < 70; A-a > 35)
|
|
|
If a patient with pneumocystosis is resistant to bactrim therapy, what is second line treatment?
|
IV pentamidine
|
|
|
what is the causative organism suspected in a person who has close contact to farm animals?
|
Coxiella burnetti
|
|
|
what antibiotics should be used against the atypical pneumomia caused by Mycoplasma, Legionella or Coxiella burnetti?
|
Macrolides, quinolones, doxycyline
|
|
|
which cultures should be obtained for a patient with pneumonia: sputum or blood?
|
both! Sputum yields result in 40% of cases, while bloods can give a more definitive diagnosis in sicker patients
|
|
|
How long after admission is the onset of pneumonia attributed to hospital acquired infection?
|
>48 hours
|
|
|
what is the best initial test for a patient suspected of having TB?
|
CXR
|
|
|
if a patient has a CXR suspicious for TB, what is the next best step in management?
|
sputum stain/culture (AFB)
|
|
|
when, in the course of investigations, should treatment begin for TB?
|
after positive CXR, before results of sputum culture are attained
|
|
|
What antibiotics are used in the treatment of TB?
|
RIPE: rifampicin, Isoniazid, Pyrazinamide*, Ethambutol* (* - only taken for first 2 months)
|
|
|
which anti-tuberculosis medication may cause gout? How is it managed?
|
Pyrazinamide. It is benign, so painkillers may be administered, but treatment continues
|
|
|
which anti-tuberculosis medication may cause optic neuritis?
|
ethambutol (cease the drug)
|
|
|
is pyrazinamide necessary for TB treatment?
|
No, but it reduces treatment from 9 months to 6 months
|
|
|
what anti-tuberculosis medication may turn urine red/orange?
|
rifampicin (this symptom is benign)
|
|
|
what anti-tuberculosis medication may cause neurological problems, and requires treatment with pyridoxine?
|
Isoniazid
|
|
|
which anti-tuberculosis medications are hepatotoxic?
|
All of them
|
|
|
when is TB treatment extended greater than 6 months?
|
osteomyelitis, TB meningitis, miliary disease, pregnancy
|
|
|
how is TB pericarditis treated?
|
steroids (pericardiectomy if progressive)
|
