Respiratory medicine is a vital branch of medical science that focuses on the diagnosis, treatment, and management of disorders affecting the respiratory system. The respiratory system plays a fundamental role in our overall health by facilitating the exchange of oxygen and carbon dioxide between our bodies and the external environment.
As a medical student, understanding the intricacies of the respiratory system is crucial, as respiratory disorders are incredibly common and can have a significant impact on patients’ quality of life. By studying respiratory medicine, you will learn about a wide range of conditions, including asthma, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and many others.
To reinforce your knowledge in this field, take the following multiple-choice questions. By doing so, you will not only enhance your knowledge but also prepare yourself for future clinical practice where respiratory conditions are encountered frequently.
Crackles-fine inspiratory DO NOT clear on coughing
No change / Reduced
Reduced both sides
Reduced bilaterally
No change / Reduced
Crackles-fine inspiratory DO clear on coughing
No change / Reduced
Reduced both sides during active disease
?both sides during active disease
Hyper-resonant
Wheeze\: expiratory polyphonic
No change
Reduced both sides
?both sides
No change
Wheeze\:inspiratory often monophonic
No change
Reduced side of collapse(ipsilaterally), trachea pulled to that side
Reduced ipsilaterally
Reduced ipsilaterally
Reduced air entry
Reduced
Reduced side of collapse
Reduced ipsilaterally
Reduced ipsilaterally
Bronchial breathing, Reduced air entry
Reduced
No change
No change
No change (Reduced if infarcted tissue)
Possible pleural rub (crunching through snow) often heard over area
No change
Reduced side of effusion (ipsilaterally), trachea pushed to other side
Reduced ipsilaterally
Reduced ipsilaterally, stoney dull
Reduced air entry
Reduced
A helpful table is shown below:
Condition
Expansion
Air entry
Percussion
Auscultation
Vocal resonance
Pneumothorax
Reduced affected side
Reduced affected side
Hyper-resonant
Reduced air entry
Reduced
COPD
Reduced both sides & hyperinflated
Reduced bilaterally
Hyper-resonant
Wheeze+/-\: expiratory polyphonic
Reduced
Pulmonary fibrosis
Reduced both sides
Reduced bilaterally
No change / Reduced
Crackles-fine inspiratory DO NOT clear on coughing
No change / Reduced
Bronchiectasis
Reduced both sides
Reduced bilaterally
No change / Reduced
Crackles-fine inspiratory DO clear on coughing
No change / Reduced
Asthma
Reduced both sides during active disease
?both sides during active disease
Hyper-resonant
Wheeze\: expiratory polyphonic
No change
Stridor
Reduced both sides
?both sides
No change
Wheeze\:inspiratory often monophonic
No change
Lobar Collapse
Reduced side of collapse(ipsilaterally), trachea pulled to that side
Reduced ipsilaterally
Reduced ipsilaterally
Reduced air entry
Reduced
Pneumonia
Reduced side of collapse
Reduced ipsilaterally
Reduced ipsilaterally
Bronchial breathing, Reduced air entry
Reduced
Pulmonary Embolism
No change
No change
No change (Reduced if infarcted tissue)
Possible pleural rub (crunching through snow) often heard over area
No change
Pleural Effusion
Reduced side of effusion (ipsilaterally), trachea pushed to other side
Reduced ipsilaterally
Reduced ipsilaterally, stoney dull
Reduced air entry
Reduced
Obstructive Sleep Apnoea (OSA)
What is the The treatment of choice for obstructive sleep apnoea?
OSA is characterised by obstruction of the upper airways during sleep. This is often from the soft tissues in the neck and upper airways.
The exact mechanism isn’t clear but there is subsequent apnoeic episodes (not breathing) and demonstrable hypoxia (O2 sats monitoring).
The condition is diagnosed via a sleep study: an apnoea monitor with continuous sats monitoring.
As a result of the hypoxia/ repetitive waking caused by apnoeic episodes patients are sleepy throughout the day. They do not however have an underlying lung parenchymal disorder so
PFT’s are normal
They are not “breathless” as a result of the OSA
The treatment of choice is CPAP which differers from intermittent positive airways pressure:
CPAP
IPPV
Continuous airways pressure
positive airway pressure higher in inspiration than expiration. can be triggered by inspiration
Airtight mask
Airtight mask
Main indications (outside of critical care environment) heart failure/ OSA
Main indication (outside of critical care environment) is COPD
OSA carries an increased risk of
Car accidents
Heart attack
Stroke
NB: The Epworth score is used by patients to mark features such as snoring/ daytime sleepiness. E.g. if you fall asleep during a conversation you’re quite likely to have OSA.
Pneumothorax consideration
A female presents to A&E with mild pleuritic right sided chest pain. A Chest X-ray reveals a small (<1cm) ring of air outside the lung at the apex. What is the correct management?
Observation Only
Aspiration under ultrasound guidance
Aspiration without ultrasound
Chest drain (seldinger technique)
Chest drain (trochar technique)
Observation Only
The pneumothorax is small. Its likely to resolve with no treatment. You can simply repeat the CXR after a period (e.g. 24-48 hours)Aspiration may be successful but is risky in such small effusions.
The British Thoracic Society suggest for a larger pneumothorax:
Aspirate effusions >2cm in diameter
Then repeat the CXR
If unsuccessful: consider either repeat aspiration or chest drain.
In essence this means that in anyone with a spontaneous pneumothorax you should consider an aspiration first.
COPD vs Asthma
What is the key distinguishing factor between COPD and asthma in pulmonary function tests?
Severity of obstruction
FEV1
FVC
Response to bronchodilators
Diffusion
Response to bronchodilators
Asthma is variable airway obstruction with diurnal variation. However a patient with asthma could have “identical” PFT’s to a patient with COPD.
The key distinguishing feature is the response to bronchodilator treatment. COPD does not classically respond, asthma typically does (>400ml).
Bronchiectasis vs ILD
Which clinical feature is most useful in differentiation of pulmonary fibrosis and bronchiectasis?
Forced expiratory time
FEV1 at bedside spirometry
The presence of fixed crackles
Wheeze
Presence of a pleural effusion
The presence of fixed crackles
In bronchiectasis the crackles often clear on coughing. This differentiates them from the fixed crackles of interstitial lung disease and pulmonary oedema.
In an exam if you hear bibasal inspiratory crackles ask the patient to cough. If the crackles clear this is evidence they are caused by bronchiectasis.
LTOT criteria
In COPD which of the following suggests a patient requires LTOT (long term oxygen therapy).
ABG PH<7.35
ABG CO2 >8
*ABG PO2<7.3 kPA
Exercise tolerance of <10 yards limited by SOB
FEV1 <33% prediced
ABG PH<7.35
ABG CO2 >7.5
ABG PO2<7.3 kPA
Exercise tolerance of <10 yards limited by SOB
FEV1 <33% prediced
ABG PO2<7.3 kPA
Common question. You have to not be suffering from a current infective illness.
I.e. if you check someones ABG when they are admitted with COPD with pneumonia this does not count.
Trial data is wearing the oxygen for >16 hours a day.
Obstructive Sleep Apnoea
What proportion of patients with obstructive sleep apnoea (OSA) have a formal diagnosis of OSA?
5%
25%
50%
75%
>90%
25%
Its thought that only 1 in 4 patients with OSA have a formal diagnosis.
Lung Cancer Operability
A patient with lung cancer is worked up for an operation. He has the following lung function tests:
FEV1 0.8L (29% Predicted)
FVC 3.1 L (92% Predicted)
He has had a CT scan chest abdo pelvis and a PET scan which show no metastatic spread and a solitary lung lesion in the right middle lobe. The cancer is biopsied at bronchoscopy and is found to be an adenocarcinoma.
Is this operable?
True
False
False.
Criteria for operability include:
There must be no pleural effusion.
There must be no LN spread.
The tumour must be “non small cell” (e.g. adenocarcinoma)
Extrathoraxic spread (e.g.to the sympathetic chain causing a Horner’s syndrome = inoperable)
Lung function tests
A patient has the following lung function tests.
FEV1 1.6L (50% Predicted)
FVC 3.2 L (92% Predicted)
What is the abnormality shown on the lung function tests?
Obstructive airways disease (Mild)
Obstructive airways disease (Moderate)
Obstructive Airways disease (severe)
Type I respiratory Failure
Restrictive Airways disease
Obstructive airways disease (Moderate)
Obstructive airways disease is where the FEV1 /FVC ratio is less than 60%. The severity of the COPD is based on the FEV1 measurement as predicted for a given persons age/ sex/ height.
by