Chest Medicine

Question 1

Airway diseases (3)

Answer 1

COPD, Asthma, Bronchiectasis

Question 2

Respiratory Diseases of the PARENCHYMA/ INTERSTITIUM (4)

Answer 2

Fibrosis, Hypersensitivity Pneumonitis,

Emphysema, pneumonia

Question 3

Respiratory Diseases of the Pluera

Answer 3

Pleural Effusion, Pleural thickening, Mesothelioma/Pleural malignancy

Question 4

Vascular problems

Answer 4

PE, Pulmonary hypertension

Question 5

Ventilation problems

Answer 5

Sleep disordered breathing, obesity hypoventilation, neuromuscular problems, thoracic cage abnormality

Question 6

Imaging for lung diseases

Answer 6

CXR, HRCT,

Question 7

Pulmonary function tests

Answer 7

Spirometry – FEV1/ VC/ FVC/ FEV1/VC ratio

Lung volumes – TLC/ RV

Transfer factor – TLCO/ KCO

Question 8

Restrictive lung diseases

Answer 8

Normal FEV1/VC

Obesity, Thoracic cage abnormalities, fibrosis, neuromuscular abnormalities

Question 9

Obstructive lung diseases

Answer 9

FEV1/VC <70%
Asthma
COPD
Bronchiectasis

Question 10

Flow Volume loops

Answer 10

Can show if airflow is appropriate for a particular lung volume. Can give an indication of where major problem is.

Large airway obstruction- flattened exp and inspir loop,

Diffuse small airway obstruction- early peaked exp loop and normal inspir loop

Intrathoracic obstruction (mediastinal tumour) have a more pronounced affect on the expiratory than inspiratory limb

Extrathorcic obstruction (goiter) has a more pronounced affect on the inspiratory than expiratory limb

Question 11

Lung volumes TLC & RV- Obstructive

Answer 11

TLC increases with hyperinflation, RV increases due to gas trapping

Question 12

Lung volumes TLC & RV- Restrictive

Answer 12

TLC- reduced

RV- normal/low

Question 13

Test of functionality of the alveolar-capillary membrane

Answer 13

Transfer factor

Question 14

Factors affecting TLCO (5)

Answer 14

1. Ventilation Perfusion Mismatch - common in many lung diseases
2. Reduction in the area of alveolar-capillary membrane - e.g. emphysema
3. Increased thickness of alveolar-capillary membrane - e.g. pulmonary fibrosis
4. Pulmonary Blood flow - e.g. pulmonary hypertension
5. Haemoglobin concentration - e.g. anaemia leads to a decrease in TLCO

Question 15

KCO

Answer 15

Transfer coefficient=functionality ‘per unit volume’ of lung.

Can increase to compensate for low TLCO if extra pulmonary causes of reduced lung volume obesity, thoracic cage abnormalities etc.

Question 16

HRCT

Answer 16

1mm slice every 10 mm, good for suspected diffuse lung conditions

Question 17

Spiral or Helical CT

Answer 17

Less resolution but done in continuum therefore dont miss small nodules etc

Question 18

Pneumoconiosis

Answer 18

Lung disease caused by mineral dust
Fibrogenic=coal, silica, asbestos
Non fibrogenic= Siderosis (Iron) Welders
Baritosis (Ba miners)

Question 19

Silicosis

Answer 19

1. Early : diffuse nodules on CXR
   Differentiate from sarcoidosis, TB, diffuse malignancy
2. Late : solid mass / upper zone
   Differentiate from lung cancer, TB
3. Restrictive lung function abnormality
   4.Characteristic findings on biopsy
   Dense fibrosis with birefringent particles

Question 20

Coal workers pneumoconiosis

Answer 20

Early : diffuse nodules on CXR
Differentiate from sarcoidosis, TB, diffuse malignancy
Late : solid mass / upper zone
Differentiate from lung cancer, TB
Restrictive lung function abnormality
Characteristic findings on biopsy
Dust accumulation around terminal bronchioles with fibrosis

Question 21

Asbestos related disease

Answer 21

Heavy exposure= Lung cancer, asbestosis

Light exposure= mesothelioma, plueral plaques (no impact on lung function), plueral fibrosis

Question 22

Transudate

Answer 22

Effusion fluid caused by changes in mechanical or oncotic pressure.

LOW protein <30g/L, LDH <200

Cardiac, renal failure, cirrhosis, ascites

Question 23

Exudate

Answer 23

Effusion fluid caused by Increased permeabiliity of cap by pleural disease

Protein>30g/L, LDH>200

Malignancy, infection, inflammation,

Question 24

Occupational asthma

Answer 24

Asthma which is caused by exposures to some agent at work (or is substantially worsened)

50% still have astham even after leaving work

Can be sensitiser (90%) Latency period between 1st exposure to a “sensitiser” and immunologically-driven symptoms

or irritant induced

Question 25

Work related asthma

Answer 25

Asthma symptoms which are increased because of exposures at work (eg exercise, dust, cold)

Question 26

Investigation of occupation asthma

Answer 26

``` History Skin prick tests Peak flow readings at work and home Airway responsiveness measurements Inhalational challenge test ``` Tx- as per standard BTS

Question 27

Chronic Bronchitis

Answer 27

Chronic or recurrent excessive mucus secretion in the bronchial tree

Question 28

Emphysema

Answer 28

An increase beyond the normal in the size of the air spaces distal to the terminal bronchiole(alveoli) accompanied by destruction of their walls and without obvious fibrosis.”

Question 29

Cor Pulmonale

Answer 29

V/Q matching process constricts blood flow around areas of hypoxia, in emphysema hypoxia is everywhere=> pulomnary hypertension,

Question 30

Type 1 Respiratory Failure

Answer 30

PaO2 < 8kPa Causes V/Q mismatch & shunt

Question 31

Type 2 Respiratory Failure

Answer 31

PaO2 < 8 kPa on air & PaCo2 > 6 kPa Causes Hypoventilation Increase in deadspace ventilation V/Q mismatch

Question 32

Symptoms suggestive of respiratory insufficiency

Answer 32

``` Breathless on exertion (dyspnoea) Breathless when lying down (orthopnoea) Poor concentration Extreme fatigue Decreased appetite Anxiety Nocturnal hypoventilation symptoms Disturbed sleep, frequent awakenings, morning headaches ```

Question 33

Investigation of respiratory insufficiency

Answer 33

1. FVC / SNIP / MIP / MEP - to measure and assess inspiratory and expiratory function 2. Overnight oximetry or transcutaneous CO2 monitoring – to assess presence of nocturnal hypoventilation 3. Arterial Blood Gas analysis – to determine urgency of treatment assessment 4. Venous bicarbonate – to measure total CO2 5. Sleep studies

Question 34

Hypoventilation

Answer 34

COPD OSA DMD

Question 35

OSA

Answer 35

Ix Epworth sleepiness score Limited somnography Oximetry only Tx Weight loss CPAP- effective at controlling Sx

Question 36

DMD & COPD

Answer 36

NIV

Question 37

Interstitial Lung disease

Answer 37

An imprecise term for a range of diseases which affect the lung parenchyma with cellular infiltration of the alveoli, interstitium and distal airways, and which may progress to fibrosis

Question 38

Types of ILD

Answer 38

1. Idiopathic Pulmonary Fibrosis 2. Sarcoidosis 3. Hypersensitivity Pneumonitis (EAA) 4. Pneumoconiosis 5. Connective tissue disease 6. Drug related interstitial disease

Question 39

IPF Tx

Answer 39

1. Nothing 2. Best Supportive Care ie:oxygen/rehab 3. Pirfenidone/Nintedanib (expensive & rare) 4. Recruit to Clinical Trials 5. Transplant

Question 40

IPF features Hx

Answer 40

- Progressive breathlessness - Dry cough - Failure to respond to treatments for other conditions

Question 41

IPF Ex findings

Answer 41

- cyanosis - clubbing - fine crackles - reduced chest expansion

Question 42

Multisystem granulomatous disease of unknown cause primarily affecting the lung

Answer 42

Sarcoid | No Tx or steroids if required

Question 43

ILD Ix

Answer 43

CXR=> HRCT Lung Function ABG Auto antibodies and serum ACE

Question 44

Bilateral Hilar/Mediastinal Lymphadenopathy

Answer 44

Sarcoid TB Lymphoma Carcinoma

Question 45

EBUS

Answer 45

Used to take biopsy mediastinal lymph nodes

Question 46

EAA (hypersensitivity Pneumonisitis

Answer 46

Presents with cough, breathlessness and sometimes systemic symptoms of fever, weight loss Occupation/Hobbies!

Question 47

EAA Ex

Answer 47

Crackles & Also wheeze and squeaks

Question 48

EAA Diagnosis

Answer 48

Usually suffice to have appropriate exposure, positive antibody response and clinical/radiological picture

Question 49

EAA Ix

Answer 49

Mosaicism on HRCT (air trapping) hallmark

Question 50

EAA Tx

Answer 50

Avoid antigen | Steroids

Question 51

IPF

Answer 51

All lung function parameters reduced Type 1 Respiratory Failure picture