Lung

Question 1

What proportion of pregnant women have asthma?

Answer 1

8%

Question 2

Most severe asthma in which weeks of pregnancy?

Answer 2

24, 25 and 26

Question 3

What is poorly controlled asthma in pregnancy linked with?

Answer 3

Pre-eclampsia
Pre-term birth
IUGR
Perinatal death
Congenital malformations

Question 4

How many women experience dyspnoea in pregnancy?

Answer 4

60%

Question 5

What can you use to monitor asthma in asthmatic pregnant women?

Answer 5

FEV1 (doesn’t change in pregnancy even though resp minute volume increases)

Question 6

How many women experience improvement/no change/worsening of their asthma in pregnancy?

Answer 6

Improvement: 34%
Unchanged: 26%
Worsen: 36%

Question 7

What improvement in FEV1 is expected after salbutamol therapy?

Answer 7

12% improvement or more

Question 8

What are the differential diagnoses for breathlessness in pregnancy?

Answer 8

Dyspnoea of pregnancy
PE
Amniotic fluid embolism
Bronchitis/pneumonia
Post nasal drip (rhinitis)
Congestive heart failure/cardiomyopathy
GORD
Vocal cord dysfunction
Dysfunctional breathing

Question 9

Management of asthma in pregnancy

Answer 9

Smoking cessation
Vaccination
Body weight
Folate
Routine monitoring
Eduction about SE and adherence
Control of environmental triggers
Inhaler techniques
Management of existing conditions

Question 10

What asthma treatments cannot/should not be used in pregnancy?

Answer 10

Leukotriene receptor antagonists
Anticholinergics
Immunotherapy

Question 11

What is the advice for oral corticosteroids?

Answer 11

Not teratogenic
Small risk of cleft lip
Associated with low birth weight and pre-eclmapsia but possible confounding variable is severity of asthma
Benefits outweigh risks of uncontrolled asthma!

Question 12

Is there any genetic link to maternal asthma?

Answer 12

ADAM33 gene is induced in allergic maternal asthma

Question 13

Advice of how to avoid allergens?

Answer 13

Remove pets from home
Encase pillow and mattress with impermeable covers
Wash sheet and blankets weekly in hot water

Question 14

Any advice for labour with maternal asthma?

Answer 14

Avoid carboprost, ergonovine and indomethacin

Instead use prostaglandin, MgSO4 or terbutaline

Question 15

What other diseases are included in the COPD diagnosis?

Answer 15

Chronic bronchitis, emphysema and asthma

Question 16

Spirometry diagnosis of COPD?

Answer 16

FEV1/FVC ratio less than 0.7

No reversibility with B2 agonists

Question 17

What is LTOT?

Answer 17

Long term oxygen therapy
Increases survival for those with chronic respiratory failure
Lowers cardiac risk and improves cognition (not as hypocapnic)

Question 18

What are the arguments for smoking cessation in COPD?

Answer 18

Improves mortality and health quality
Makes oxygen less risky
Inhalers work better
Less exacerbations
Improves mental and cardiovascular health

Question 19

Treatment of COPD?

Answer 19

Inhaled antimuscarinics + LABAs + steroids
Stand by oral steroids and antibiotics
Mucolytics

Question 20

What can be offered for repeated infective exacerbations of COPD?

Answer 20

Long term macrolide antibiotics

eg clarithromycin

Question 21

What is interstitial lung disease?

Answer 21

Any disease that affects the space between alveolar epithelium and capillary endothelium
Inflammation, fibrosis and remodelling

Question 22

Name 3 exposure related ILD causes

Answer 22

Occupational (asbestosis)
Environmental (dust mite hypersensitivity)
Medication (bleomycin)
CT disease

Question 23

Name the major idiopathic pulmonary fibroses

Answer 23

Idiopathic pulmonary fibrosis
Idiopathic non specific interstitial pneumonia
Respiratory bronchiolitis interstitial lung disease

Question 24

What is the most frequent ILD?

Answer 24

Idiopathic pulmonary fibrosis
Incidence is increasing
Median survival 3 yrs

Question 25

Risk factors for idiopathic pulmonary fibrosis

Answer 25

``` Genetics (MUC58, TOLLIP, Telomerase) Cigarette smoking > 20 pack years Metal and woods dusts, farming, raising birds, stone cutting Herpes viruses, EBV, CMV, Hep C GORD ```

Question 26

Presentation of idiopathic pulmonary fibrosis

Answer 26

``` Increases with age, males more than females Exertional dyspnoea Dry cough Digital clubbing Diffuse inspiratory crackles ```

Question 27

Diagnosis of idiopathic pulmonary fibrosis relies on:

Answer 27

Exclusion of other ILDs (CT diseases, environmental exposures, medications) Presence of 'Usual Interstitial Pneumonia' (UIP) pattern on chest High Res Chest CT/surgical lung biopsy

Question 28

What does the 'usual interstitial pneumonia' pattern if disease involve?

Answer 28

``` Bilateral patchy fibrosis Basal/peripheral predominance Reticular line and fibroblast foci Honeycombing Traction bronchiectasis Architectural distortion ```

Question 29

When is a lung biopsy taken?

Answer 29

In ILD if HR CT is nor diagnostic Mortality is 1-3% Can have serious complications (pneumothorax, pneumonia, empyema, haemothorax)

Question 30

What factors are involved in the pathogenesis of ILD?

Answer 30

Myofibroblast accumulation and angiogeneis TGFBeta, CTGF, ET-1, PDGF, VEGF Excessive ECM and collagen

Question 31

Treatment of ILD?

Answer 31

``` Pulmonary rehab O2 therapy Symptom control Lung transplantation Pirfenidone (anti TGF beta) Nintedanib (anti PDGF, VEGF, FGF) ```

Question 32

What pattern of disease is seen in TB?

Answer 32

Apical lung cavitation | Casseous necrosis

Question 33

Presentation of TB

Answer 33

Night sweats Cough Weight loss (for 6 months?)

Question 34

How is the diagnosis of TB made?

Answer 34

Sputum Ziehl-Nielsen stain Induced sputum (culture takes weeks) Bronchoscopy

Question 35

Describe how a TB culture is done?

Answer 35

Induced sputum culture Decontamination of specimens to avoid bacterial overgrowth Solid media Bactec 460 radiometric culture detects CO2 production so only takes 1-3 weeks

Question 36

Treatment of TB

Answer 36

``` Rifampicin Isoniazid Pyrazinamide Ethambutol (for 6 months minimum) Nutritional support Steroids? ```

Question 37

Why is drug resistance a threat?

Answer 37

Can take 18months of treatment if multiple drug resistant | Totally drug resistant strain found in India in 2012

Question 38

Why are cavities and extracellular matrix destruction key to the success of TB?

Answer 38

Spread of organism Cavities permit immune evasion Other mycobacteria and fungi can colonise cavities Aerosol super-spreaders

Question 39

What are MMAs?

Answer 39

Matrix metalloproteinases Can degrade fibrillar collagens at neutral pH Are needed for cavity formation and transmission Doxycycline suppresses MMP secretion and TB growth

Question 40

What is the role of MMAs in treatment?

Answer 40

Doxycycline suppresses MMP secretion and TB growth | Decreases cavitation and spread